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FRONTISPIECE. 




-i»r~" 




DESCRIPTION OF FRONTISPIECE. 



& 


Bladder (turned down). 


R 


Rectum. 


L 


Round ligament. 


U 


Uterus. 


0. 


Ovary. 


V 


Vagina. 


s. 


Sacro-iliac synchondrosis. 


K. 


Kidney. 


T. 


Fallopian tube. 


P. 


Pubic symphysis. 


a. 


Pyriformis muscle (cut). 


b. 


Gluteal muscles. 


c. 


Coccygeus muscle. 


d. 


Obturator interims. 


e. 


Psoas magnus. 


/■ 


Linea alba. 


9,9 


Ureters. 


. h. 


Obturator nerve. 


i. 


Internal abdoMinal ring. 


k. 


Great sacro-sciatie ligaMent. 


1. 


Abdominal aorta. 



SIDE VIEW OF THE FEMALE PELVIS (Fig. 1). 

2. Inferior Mesenteric artery. 
3, 3. Common iliac arteries. 

4. Left external iliac artery. 

5. Vena cava inferior. 

6, 6. Renal veins. 

7, 7. Common iliac veins. 

8. External iliac vein. 

9. Internal iliac artery (cut). 

10. Gluteal vein. 

11. Ilio-Iumbar vein. 

12. Lateral sacral vein. 

13. Sciatic vein. 

14. Pudic vein. 

15. Obturator vein. 

16. Epigastric vein. 

17. Uterine veins. 

18. Vesico-vaginal veins. 

19. Ovarian veins. 

20. Bulb of the ovary. 

21. Vein to round ligament. 

22. Fallopian veins. 



FEMALE PERINEUM AND ISCHIORECTAL REGION (Fig. 2). 



, Coccyx. 
Gluteus maximus. 

Fascia lata, inserted into pubic arch. 
Tuberosity of ischium. 
Internal sphincter ani. 
External sphincter ani. 
Attachment of sphincter ani to coccyx. 
Levator ani, forming floor of ischio-rectal 

fossa. 
Perineum. 

Transversus peronei muscle. 
Erector clitoridis. 
Constrictor vaginje. 
Glands of Bartholin:. 
Urethral opening. 
Labia majora. 



Labia minora. 

Clitoris. 

Mons Veneris. 

Internal pudic artery. 

External hemorrhoidal artery. (The three arte- 
ries of this name are shown, the middle one 
only being marked.) 

Superficial perineal artery. (Supplying anus, 
perineum, vaginal lips, and erector clito- 
ridis ) 

Transversus peronei artery. 

Deep branch of internal pudic artery. 

Artery of the bulb (arteria bulbosaj. 

Internal pudic vein (common). 

External hemorrhoidal vein. (Other branches 
of the same vessel not marked.) 



AN AMERICAN 

TEXT-BOOK OF GYNECOLOGY, 

MEDICAL AND SURGICAL, 

FOR 

PRACTITIONERS AND STUDENTS. 

BY 

HENRY T. BYFORD, M.D., J. M. BALDY, M.D., 

EDWIN B. CRAGIN, M.D., J. H. ETHERIDGE, M.D., 

WILLIAM GOODELL, M.D., HOWARD A. KELLY, M.D., 

FLORIAN KRUG, M.D., E. E. MONTGOMERY, M.D., 

WILLIAM R. PRYOR, M.D., GEORGE M. TUTTLE, M. D. 



EDITED BY 

J. M. BALDY, M.D. 



SECOND ED HI ON, REVISED. 



WITH 341 ILLUSTRATIONS. IN THE TEXT, AND 38 COLORED 
AND HALF-TONE PLATES. 



PHILADELPHIA: 

W. B. SAUNDERS, 

925 Walnut Street. 
1898. 



1*573 



Copyright, 1898. by 
W. B. SAUNDERS. 



\i\ foster 



' 



flQlO] 




Efc 



ELKCTROTYl'KI) l:Y 
WBSTCOTT II THOMSON, PHILADA. 



PRESS OP 
SAUNDERS, PHILADA. 



MEDICAL PROFESSION OF AMERICA, 

BY 

THEIR CO-WORKERS, 
THE AUTHORS. 



LIST OF AUTHORS. 



J. M. BALDY, M. D., 

Professor of Gynecology in the Philadelphia Polyclinic ; Gynecologist to the Hospital of 
the Philadelphia Polyclinic; Surgeon to the Gynecean Hospital; Gynecologist to the 
Pennsylvania Hospital ; Consulting Gynecologist to the Frederick Douglass Memorial 
Hospital, Philadelphia. 

HENRY T. BYFORD, M.D., 

Professor of Gynecology and of Clinical Gynecology, College of Physicians and Surgeons, 
Chicago; Professor of Clinical Gynecology in the Woman's Medical School of the 
Northwestern University; Professor of Gynecology in the Post-Graduate Medical 
School, Chicago. 

EDWIN B. CRAGIN, M. D., 

Assistant Gynecologist to the Eoosevelt Hospital ; Consulting Gynecologist to the New 
York Infirmary for Women and Children; Consulting Obstetrician to the Maternity 
Hospital, New York. 

JAMES H. ETHERIDGE, M. D., 

Professor of Gynecology and Obstetrics, Rush Medical College, Chicago; Professor of 
Gynecology, Chicago Polyclinic; Gynecologist to the Presbyterian Hospital; Consulting 
Gynecologist to St. Joseph's Hospital, Chicago. 

WILLIAM GOODELL, M.D., 

Professor of Gynecology in the University of Pennsylvania, Philadelphia. 

HOWARD A. KELLY, M.D., 

Professor of Gynecology and Obstetrics in the Johns Hopkins University, Baltimore; 
Gynecologist and Obstetrician to the Johns Hopkins Hospital. 

FLORIAN KRUG, M.D., 

Professor of Gynecology in the New York Polyclinic; Visiting Gynecologist to the 
German Hospital, New York. 

E. E. MONTGOMERY, M.D., 

Professor of Clinical Gynecology in the Jefferson Medical College, Philadelphia ; Gyne- 
cologist to the Jefferson Medical College Hospital and to St. Joseph's Hospital, Phila- 
delphia. 

WILLIAM R. PRYOR, M.D., 

Professor of Gynecology in the New York Polyclinic; Visiting Gynecologist to the St. 
Elizabeth Hospital ; Consulting Gynecologist to the City Hospital, New York. 

GEORGE M. TUTTLE, M.D., 

Professor of Gynecology in the College of Physicians and Surgeons, New York ; Attending 
Gynecologist to the Roosevelt Hospital ; Consulting Surgeon to the New York Cancer 
Hospital and the New York Infirmary for Women and Children. 



PREFACE TO THE REVISED EDITION. 



In offering a revised edition of this book to the profession it has 
been our aim to render it as nearly complete as is consistent with a 
clear enunciation of the practical working of gynecology. Much new 
material has been added, and some of the old eliminated or modified. 
This has been necessitated by the very rapid improvements in meth- 
ods and details during the past four years. A large number — more 
than forty — of the old illustrations have been replaced by new ones, 
all of which add very materially to the elucidation of the text ; they 
picture methods, not specimens. The descriptions of the prepara- 
tion for each operation and the after-management of patients have 
been relegated to the chapters on Technique and After-treatment. 
This has of course entailed a very considerable enlargement of these 
chapters, but has relieved the body of the book from continued repe- 
tition. It has been found necessary to rearrange much of the 
material. The chapter on the Bladder, Urethra, and Ureters is 
extensively altered. The portions devoted to plastic work have been 
so generally improved as to be practically new. Hysterectomy, 
both abdominal and vaginal, has been re-written and more freely 
illustrated. All descriptions of operative procedures have been 
carefully revised and fully illustrated. The editor feels grateful 
to the profession for the considerate reception of the first edition, 
and hopes for an equally favorable one for the second. He has 
profited by kindly criticisms, and in the revision, making allowances 
for honest differences of opinion, has followed suggestions as far as 
he has felt them compatible with clear teaching. 

J. M. BALDY. 



PREFACE. 



The rapid and progressive advances in the science and art 
of Gynecology during the past dozen years have created an 
almost constant necessity for the revision of works on this sub- 
ject. For this reason, and for the purpose of presenting gyne- 
cological surgery and treatment as it is practised in America, the 
country of its birth and of its most substantial improvements 
and progress, the present text-book has been prepared by Amer- 
ican authors, all of whom are teachers of this branch of surgery 
in the leading medical schools and hospitals. It is thoroughly 
practical in its teachings, and is intended, as its title implies, to 
be a working text-book for physicians and students. Many of 
the most important subjects are considered from an entirely 
new standpoint, and are grouped together in a manner some- 
what foreign to the accepted custom. Several new chapters have 
been added, such as Technique and After-treatment, it being 
hoped that by this presentation of the subject the student might 
the more readily be aided in an intelligent understanding of 
their details. Illustrations have been depended upon in great 
measure to demonstrate and explain the anatomy of the parts 
considered — a method of dealing with the subject which has 
relieved the text of much irrelevant and cumbersome matter. 

The work embodies as nearly as possible the combined opinions 
of all the authors, although it is to be understood that each indi- 
vidual author must be free from absolute responsibility for any 
particular statement : especially is this so for the reason that 
the Editor has endeavored by adding to and subtracting ffoin 
the text to render it as uniform in its statements as possible. 



x PREFACE. 

All extraneous matter and discussions have been carefully ex- 
cluded, and the attempt has been made to allow nothing unneces- 
sary to cumber the text, which is brought fully up to date at every 
point. 

The subject-matter of this work has been enforced by illustra- 
tions wherever opportunity presented. A large proportion of these 
illustrations are original, and are mostly reproduced from photo- 
graphs or from fresh specimens. A considerable number of wood- 
cuts and several half-tone and colored plates have been taken from 
other authors, and are credited to them in the List of Illustrations. 

The Editor desires to thank Dr. Frank W. Talley for his 
careful revision of the proof-sheets, for his preparation of the 
Index, and for his valuable aid in other ways, and to express 
appreciation of the efficient and ever-ready co-operation of Mr. 
W. B. Saunders. 

J. M. BALDY. 
Philadelphia, Dec. 1, 1893. 



CONTENTS, 



PAGE 

EXAMINATION OF THE FEMALE PELVIC ORGANS 17 

THE TECHNIQUE OF GYNECOLOGICAL OPERATIONS 43 

MENSTRUATION AND ITS ANOMALIES 69 

STERILITY Ill 

ANOMALIES OF THE FEMALE GENERATIVE ORGANS 118 

GENITAL TUBERCULOSIS 132 

DISEASES OF THE VULVA AND VAGINA (NON-MALIGNANT) . . 152 

INFLAMMATORY DISEASES OF THE UTERUS 190 

LACERATION OF THE SOFT PARTS 231 

GENITAL FISTULA , 257 

DISTORTIONS AND MALPOSITIONS 268 

MALIGNANT DISEASES OF THE FEMALE GENITALIA 353 

BENIGN UTERINE NEOPLASMS 387 

PELVIC INFLAMMATION 421 

ECTOPIC GESTATION 518 

DISEASES OF THE OVARIES, INCLUDING TUBAL ANOMALIES 

AND BROAD-LIGAMENT CYSTS 544 

DISEASES OF THE URETHRA, BLADDER, AND URETERS 608 

AFTER-TREATMENT IN GYNECOLOGICAL OPERATIONS 670 



LIST OF ILLUSTRATIONS. 



FIG. PAGE 

1. Normal Position of the Uterus (Byford) 22 

2. Digital Eversion of the Rectum (Thomas and Munde) 23 

3. Palpation of the Coccyx (Byford) 24 

4. Rectal Palpation of the Uterus, drawn down by a Vulsellum Forceps (Byford) . 25 

5. Bimanual Palpation of the Uterus (Byford) 26 

6. Bimanual Rectal Palpation of the Pelvis (Byford) 27 

7. Bimanual Recto-vaginal Palpation of the Uterus (Byford) 28 

8. Sims's Uterine Elevator 32 

9. Replacement of the Uterus with the Sound. First Motion (Byford) 32 

10. Replacement of the Uterus with the Sound. Second Motion (Byford) ... 33 

11. Byford's Uterine Elevator 33 

12. Action of Byford's Uterine Elevator (Byford) 34 

13. Sims's Speculum, introduced (Byford) 35 

14. Uterine Applicator 35 

15. Bivalve Speculum, introduced (Byford) 37 

16. Passage of the Uterine Sound in Case of Anteflexion with Retroversion (Byford). 37 

17. Palpation of the Interior of the Bladder (Winckel) 41 

18. Exploratory Curette 42 

19. Sterilizer, Demijohn, Basin-holder, Sponges, Drainage-tubes, Syringes, Sutures, 

etc. (Baldy) 46 

20. Placing Instruments in Arnold's Sterilizer, in Linen Bag (Kelly) 50 

21. Silk in Tubes for Sterilization (Kelly) 51 

22. Glass Drainage-tube 57 

23. Hard-rubber Syringe, for cleansing Drainage-tube 57 

24. Robb's Modification of Kelly's Leg-holder 58 

25. Assistant supporting Legs (Kelly) 59 

26. Opening the Peritoneum (Kelly) 61 

27. Method of Enlarging the Abdominal Incision (Kelly) 63 

28. Vertical Section through the Mucous Membrane of the Uterus (Turner) ... 80 

29. Menstrual Endometrium (Weber) 80 

30. Menstrual Pad 85 

31. Membranes of Membranous Dysmenorrhea (Simpson) 101 

32. Apparatus for Artificial Impregnation (Vulliet et Lutaud) 117 

33. Development of the External Genital Organs (Schroeder) 118 

34. Malformation of the External Genital Organs (Schroeder) 118 

35. Pseudo-hermaphrodism proper (Pozzi) 121 

36. Pseudo-hermaphrodism proper (Pozzi) 122 

37. Solid Rudimentary Uterus (Forster) 126 

38. Uterus Bipartitis (Rokitansky) 126 

39. Infantile Uterus (Schroeder) • 126 

40. Uterus Unicornis (Schroeder) 127 

41. Uterus Bicornis (Schroeder) , 127 

42. Bicorn Unicervical Uterus (Barnes) 128 

43. Uterus Septus (Kussmaul) 128 



xiv LIST OF ILL USTBA TIONS. 

FIG. PAGE 

44. Didelphic Uterus and Divided Vagina (Oliver) 129 

45. Lupus Hypertrophicus et Perforans of the Vulva {Arch, fur Gynecologie) . . 133 

46. Lupus of the Vulva {Arch, fur Gynecologie) 134 

47. Tuberculosis of Cervix Uteri (Cornil) 136 

48. Tubercular Pyosalpinx with Tubercular Ovary (Baldy, from photograph in 

possession of Dr. B. C. Hirst) 140 

49. Hypertrophy of the Clitoris (Tait) 153 

50. Follicular Vulvitis (Auvard) 156 

51. Normal Vulvo-vaginal Gland (Tarnier) 157 

52. Simple Vegetations of the Vulva (Tarnier) . 162 

53. Plexus of Veins of the Vestibule (Kobelt) 163 

54. Hernia Labialis Inguinalis (Winckel) 166 

55. Hernia Vaginalis Labialis (Winckel) 167 

56. Hernia Vaginalis Labialis, extending into the Labium Major (Winckel) . . 167 

57. Elephantiasis of the Labia (Scanzoni) 168 

58. Fibroid of the Left Labium Majus (von Schiele) 169 

59. Cyst of the Eight Labium Majus (Baldy, from photograph in possession of 

Dr. B. C. Hirst) 170 

60. Cystic Tumor of the Clitoris (Meigs) 170 

61. Tumor of the Clitoris (Emmet) 171 

62. Adipose Tumor of the Left Labium (Goodell) 171 

63. Fibro-papillary Hypertrophy of the Hymen in a case of Vaginismus (Winckel). 174 

64. Vaginal Plug 175 

65. Atresia of the Hymen (Breisky) 176 

66. Complete Occlusion of the Vagina (Barnes) 177 

67. Hypertrophied Vaginal Walls above an Atresia of the Vagina (Breisky) . . 179 

68. Septate Uterus and Double Vagina, with Retention of Menstrual Fluid on 

the Left Side (Byford) 180 

69. Simple Vaginitis (Ruge) 183 

70. Granular Vaginitis (Ruge) 183 

71. Adhesive Vaginitis (Ruge) 184 

72. Emphysematous Vaginitis (Ruge) 184 

73. Cyst of the Posterior Vaginal Wall (Winckel) 189 

74. Fibre of the Endometrium, showing different grades of corpuscular develop- 

ment (Johnstone) 190 

75. Lymphatics of the Uterus (Poirier) 191 

76. Normal Mucous Membrane of the Cervix (Wyder) 192 

77. Transverse Section through the Upper Part of the Cervix, showing the 

entire Mucous Membrane (Cornil) 193 

78. Menstruating Endometrium (Johnstone) 194 

79. Endometrium, showing Exhaustion of the whole Structure (Johnstone) . . . 195 

80. Benign Adenomatous Degeneration, or Hypertrophic Glandular Endometritis 

{Arch, fur Gynecologie) 196 

81. Glandular Endometritis ; Polypoid Form (Wyder) 197 

82. Diffuse Papillary Adenoma of the Body of the Uterus with Polypi (Winckel) . 198 

83. Section of a Glandular Uterine Polypus (Cornil) 199 

84. Interstitial Endometritis, with complete Atrophy of the Glands (Wyder) . . 200 

85. Puerperal Endometrium removed by Curetternent on the seventh day [Arch. 

fur Gynecologie) 205 

86. Cocci from an Empyema; prepared by Gram's Method (von Jaksch and 

Cagney) 206 

87. (ionococci in Cells and between Cells (Stengel) . 209 

88. Instruments in Position for Dilatation of the Cervix Uteri (Baldy) 211 



LIST OF ILLUSTRATIONS. xv 

FIG. PAGE 

89. Sharp Curette 212 

90. Bulb Syringe 212 

91. Braun's Intra-uterine Syringe 213 

92. Instruments for applying the Intra-uterine Tampon (Burrage) 213 

93. Tamponing the Uterus with Iodoform Gauze by means of the Intra-uterine 

Packer (Baldy) 213 

94. Vertical Section of Endometrium three months after curettement (Nouv. Arch. 

d' Obstetrique et de Gyne'cologie) 217 

95. Vertical Section of the Uterine Mucous Membrane fifty-three days after the 

application of a Caustic {Nouv. Arch, d' Obstetrique et de Gyne'cologie) . . 218 

96. Perpendicular Section of the Uterine Mucous Membrane thirteen days after 

curettement (Nouv. Arch. d'Obste'trique et de Gyne'cologie) 219 

97. Perpendicular Section of the Uterine Mucous Membrane thirty-one days 

after curettement (Nouv. Arch. d'Obste'trique et de Gyne'cologie) 219 

98. Mucous Polypi from the interior of the Cervix and upon the surface (Pozzi) . 223 

99. Simple Papillary Erosion of the Cervix (Pozzi) 224 

100. Simple Follicular Cysts of the Cervix (Auvard) 224 

101. Subinvolution (Cruveilhier) • . . . . 228 

102. 103. Side and Front Views of a Simple Bilateral Laceration of the Cervix, 

requiring no treatment (Kelly) 232 

104. Front View of a Unilateral Laceration of the Cervix, requiring no treatment 

(Kelly) 233 

105. Side View of a Unilateral Laceration (Kelly) 233 

106. Side View of a Unilateral Laceration of the Cervix, requiring treatment 

(Kelly) 233 

107. Front View of a Bilateral Laceration of the Cervix, showing eroded area 

and Nabothian Follicles (Kelly) 233 

108. Tenacula in Place, showing eversion of a lacerated Cervix (Kelly) 233 

109. Tenacula Crossed, showing the method of approximating the lacerated lips 

and demonstrating the true condition (Kelly) .• 233 

110. Incision in the Angles of the Laceration (Kelly) 235 

111. Method of Denudation (Kelly) 235 

112. 113. Silkworm-gut Sutures in place on one side, ready to be tied. Front and 

Lateral Views (Kelly) 236 

114. Silkworm-gut Sutures in Place; intervening approximation of sutures of fine 

silk (Kelly) 237 

115. Virginal Vaginal Outlet (Baldy) 238 

116. Relaxed Vaginal Outlet as seen in the Dorsal Position (Kelly) 240 

117. Appearance of Relaxed Vaginal Outlet in Sims's Position (Kelly) 241 

118. Looking down on the Floor of the Pelvis. Dotted lines indicate the area to 

be denuded (Kelly) 242 

119. Emmet's Perineorrhaphy. Rectocele caught in tenaculum (Penrose) .... 242 

120. Method of Denuding the Sulcus (Penrose) 242 

121. Left Sulcus Denuded (Penrose) 243 

122. Both Sulci Denuded (Penrose) 243 

123. V-shaped Suture introduced and ready to be tied (Kelly) 244 

124. V-shaped Suture tied and Superficial Catgut Sutures in place (Kelly) .... 244 

125. Sutures tied on Right, and in place ready to be tied on Left Side (Kelly) . . 244 

126. Sutures of both Sides tied and the Crown Sutures in place (Kelly) 245 

127. Completed Operation (Kelly) 245 

128. Introduction of Sutures (Penrose) 246 

129. Sutures introduced in both Sulci (Penrose) 246 

130. Method of Securing Sutures with Shot (Penrose) 246 



xvi LIST OF ILLUSTRATIONS. 

FIG. PAGE 

131. Both Sulci Closed (Penrose) 246 

132. Sutures for Closing Superficial Perineum (Penrose) 247 

133. Operation Complete (Penrose) 247 

134. Speculum introduced into Vagina, showing the result of the operation 

(Kelly) 248 

135. Normal Sphincter; no break in the Continuity of the Circular Fibres (Kelly) . 249 

136. Slight Solution of Continuity in the Sphincter filled in with Connective Tissue. 

No impairment of function (Kelly) 249 

137. Sphincter Completely Ruptured, divided ends being widely separated. 

Complete loss of function (Kelly) . 249 

138. Solution of Continuity imperfectly bridged over with Connective Tissue. 

Partial loss of function (Kelly) 249 

139. Rupture of the Recto-vaginal Septum (Kelly) 252 

140. Rectal Sutures in Place (Kelly) 254 

141 . Rectal Sutures tied and Sutures, supporting ends of Sphincter Muscle, in place ; 

also Vaginal Sutures (Kelly) 254 

142. Sutures within the Vagina tied ; External Sutures in place (Kelly) .... 254 

143. Denudation and Sutures for repair of Complete Laceration (Penrose) . . . 255 

144. Completed Operation for Sphincter Tear (Penrose) 255 

145. The various Forms of Vesical Fistula (Kelly) 257 

146. Vesico-uterine Fistula (Kelly) . 260 

147. Vesico-uterine Fistula divided into two channels by a Septum of Scar-tissue 

(Kelly) 260 

148. Vesico-utero-vaginal Fistula (Kelly) 261 

149. Vesico-vaginal Fistula; bladder adherent to the uterus along the darkly 

shaded line (Kelly) 263 

150. Operation for Vesico-vaginal Fistula (Kelly) 264 

151. Diagram of Pathological Anteflexion (Schultze) 269 

152. 153, 154, 155. Congenitally Enlarged Cervix and Operation for its Repair 

(Pryor) 274 

156. Extreme Retroflexion (Barnes) 279 

157. Ventro-recto-vaginal Reduction in Uterine Retro-displacement (Brandt) . . 281 

158. Bimanual Reposition of the Retroflexed Uterus ; first step (Schultze) . . . 282 

159. Bimanual Reposition of the Retroflexed Uterus ; second step (Schultze) . . 283 

160. Bimanual Reposition of the Retroflexed Uterus; elevation of the fundus by 

the internal hand (Schultze) 284 

161. Bimanual Reposition of the Retroflexed Uterus; the external hand taking 

charge of the fundus (Schultze) 285 

162. Bimanual Reposition of the Retroflexed Uterus, completed (Schultze) . . . 286 

163. Uterine Repositor .... 287 

164. Replacement of Retrodisplaced Uterus by means of the Uterine Repositor, 

in the knee-chest position (Baldy) 287 

165. Sims-Pryor Uterine Repositor 288 

166. Frozen Section of a Girl aged Thirteen Years, showing direction of intra- 

abdominal pressure (Simington) 289 

167. Waldeyer's Frozen Section of a Female Pelvis (Henle) 290 

168. Diagnosis and Reduction of Retroflexion by the Sound (Courty) 291 

169. Introduction of Pessary, first stage (Baldy) 294 

L70. Introduction of Pessary, second stage (Croom) 294 

171. Introduction of Pessary, third stage (Croom) . 295 

172. Introduction of Pessary, fourth stage (Croom) 295 

173. Pessary for Complete Prolapse 296 

174. Uauze Plug back of Uterus (Pryor) 298 



LIST OF ILLUSTRATIONS. xvii 

FIG. PAGE 

175. Operation proposed by Wylie and Baer for Retro-displacement of the Uterus 

(Wylie) 300 

176. Operation proposed by Dudley for Uterine Retro-displacement (Baldy) . . . 300 

177. Retroversion of Slight Degree (Winckel) 301 

178. Round Ligament and its Topographical Anatomy (Maclise) 302 

179. Round Ligament and its Topographical Anatomy (Maclise) 303 

180. Alexander's Operation. Incision through aponeurosis of external oblique 

(Edebohls, Amer. Gyn. and Obstet. Journ.) 304 

181. Isolation of Round Ligament (Edebohls) 304 

182. Drawing out Round Ligament (Edebohls) 304 

183. Deep Tier of Sutures, loose (Edebohls) 305 

184. Deep Tier of Sutures, drawn tight (Edebohls) 306 

185. Superficial Tier of Buried Sutures (Edebohls) 306 

186. Sutures in Position in Hysterorrhaphy (Baldy) 307 

187. Sutures in situ in the Abdominal Wall after Hysterorrhaphy (Baldy) . . . . 309 

188. Varieties of Prolapsus (Kelly) 311 

189. Vertical Mesial Section of Prolapsus Uteri (Hart) 312 

190. Complete Prolapse of the Uterus (Boivin) 313 

191. Complete Prolapsus Uteri, showing ulcer; also hypertrophy of the mucous 

membrane (Baldy, from photograph in possession of Dr. B. F. Baer) . . 314 

192. The arrow shows the direction of force in case of a normal perineum when 

straining at stool (Pryor) 315 

193. The perineum, being ruptured, no longer resists, and the resulting condition is 

shown when straining at stool (Pryor) 315 

194. Cystocele and Rectocele (Munde) 316 

195. Showing effect of Intra-abdominal pressure on the Uterus in anteflexion with 

intact pelvic floor (Kelly) 317 

196. Pelvic Floor broken down, Uterus in retroflexion. Intra-abdominal pressure 

increases the displacement (Kelly) 317 

197. Illustrating the Formation of a Complete Prolapsus (Kelly) 318 

198. Tamponade of the Vagina in the Knee-chest Position (Baldy) 322 

199. Braun's Colpeurynter 322 

200. Freund's Operation for Complete Prolapse (Pryor) 325 

201. Operation for Prolapse. Uterus amputated. Sutures applied (Baldy) . . . 327 

202. Sutures tied (Baldy) 328 

203. Peritoneum whipped together. Operation completed (Baldy) 329 

204. Fixation of Cervical Stump to Abdominal Wall for Prolapse (Baldy) .... 330 

205. Elongation of the Infravaginal Portion of the Cervix (Kelly) 332 

206. Simple Amputation of the Cervix, stitches in situ (Baldy) 333 

207. Simple Amputation of the Cervix, stitches tied (Baldy) 334 

208. Profile of the Wedge-shaped Amputation of the Cervix Uteri, sutures in 

place (Baldy) 335 

209. Profile of the Wedge-shaped Amputation of the Cervix Uteri, sutures ready 

to tie (Baldy) 336 

210. Wedge-shaped Amputation of Cervix. Incision inner side of anterior lip 

(Pryor) 336 

211. Incision outer side anterior lip (Pryor) 336 

212. Amputation, both lips completed. Placing sutures (Pryor) 337 

213. Wedged-shaped Amputation of the Cervix Uteri, sutures tied (Baldy) . . . 337 

214. Sims's Anterior Colporrhaphy, stitches in situ (Pryor) 339 

215. Stoltz's Operation for Cystocele and Hegar's Operation for Rectocele (Munde). 340 

216. Sutures tied in Stoltz's Operation for Cystocele. Stitches in place ready for 

tying in Hegar's Operation for Rectocele (Munde) 341 



xviii LIST OF ILLUSTRATIONS. 

FIG. PAGE 

217. Profile View of Hegar's Operation of Perineorrhaphy (Pryor) 342 

218. Flap-splitting for Incomplete Laceration of the Perineum (Macphatter) . . 344 

219. Flap-splitting for Complete Laceration of the Perineum (Macphatter) . . . 345 

220. Introduction of Sutures in Flap-splitting Operation (Baldy) 346 

221. Inversion of the Uterus (Jeancon) 348 

222. Complete Inversion of the Uterus (Biot) 349 

223. Thomas's Operation for Replacement of an Inverted Uterus (Thomas) . . . 351 

224. Sarcoma of the Body of the Uterus (Baldy) 361 

225. Epithelioma of the Cervix Uteri (Baldy) 366 

226. Malignant Adenoma of Uterine Mucous Membrane, beginning glandular 

epithelium (Ruge and Veit) 378 

227. Carcinoma of the Body of the Uterus (Baldy) 379 

228. Section of an Ovary, showing its surface covered with papillomata (Doran) . 383 

229. Papillomatous Cystic Tumor of the Ovary (Doran) 383 

230. Papillomatous Disease of the Broad Ligaments (Doran) 384 

231. Sarcoma of both Ovaries {Annals of Gynecology) 385 

232. Small Muriform Polyp of the Cervix (Pozzi) 387 

233. Intra-uterine Fibroid Polyp (Baldy, from photograph in possession of Dr. 

B. F. Baer) 388 

234. Uterine Fibro-myoma, microscopic view (Pozzi) 389 

235. Submucous Uterine Fibroma (Baldy) 390 

236. Submucous Fibroid Tumor of the Uterus (Baldy) 390 

237. Large Fibrous Interstitial Tumor of the Uterus (Sims) 391 

238. Subperitoneal Pedunculated Fibroid of the Uterus (Labbe) 391 

239. Interstitial Fibroid of the Uterus (Farre) 392 

240. Calcareous Degeneration of Fibroma (Baldy, from specimen in possession of 

Dr. C. B. Penrose) 392 

241. Pedunculated Fibroid with Abdominal Evolution (Pozzi) 393 

242. Enlarged Blood-vessels on the Surface of a Fibroid (Baldy) 394 

243. OZdematous Submucous Fibroid (Carswell) 397 

244. Removal of Fibroma by Morcellation (Pean) 402 

245. Subperitoneal Nodular Fibroid Tumor of the Uterus (Baldy) - . 403 

246. Method of Removal of Subserous Uterine Fibroid (Baldy) 404 

247. Enucleation of an Interstitial Myoma (Pozzi) 405 

248. Knot of Rubber Ligature secured. by a Silk Ligature (Pryor) 406 

249. Serre-nceud for Hysterectomy 406 

250. Relation of the Ureters and Uterine Arteries to the Cervix (Pozzi) 408 

251. Left to Right Amputation of Uterus (Kelly) 409 

252. Dcschamp's Needles 411 

253. Pan-hysterectomy. Uterus freed to Uterine Arteries. Left Uterine Artery 

exposed (Pryor) 412 

254. Left Uterine Artery in Process of Ligation (Pryor) 413 

255. Left Uterine Artery Ligated and Cut. Right Uterine Artery being ligated 

(Pryor) ' 413 

256. Operation Completed (Pryor) 414 

257. Intra-ligamentous Fibroma (Pozzi) 417 

258. Suture of the Peritoneum and Fibrous Tissue left after the Detachment of a 

Firm Adhesion from the Intestine (Pozzi) 418 

259. Normal Fallopian Tube ; microscopic section (Wyder) 433 

260. Hydrosalpinx (Baldy, from photograph in possession of Dr. Brokaw) . . . . 434 

261. Hydrosalpinx (Annals of Gynecology) 435 

262. Chronic Interstitial Salpingitis and Ovaritis, with thickened broad ligament- 

so-called cellulitis ( Baldy) 437 



LIST OF ILLUSTRATIONS. xix 

FIG. PAGE 

263. Fallopian Tube and Ovary, showing adhesions (Baldy) 438 

264. Double Pyosalpinx and Diseased Uterus (Baldy) 439 

265. Pyosalpinx and Ovarian Abscess {Arch, fur Gynecologie) 440 

266. Broad thin Band of Adhesions (spider-web) hanging from an Adherent Ovary 

and Fallopian Tube (Baldy) 443 

267. Ovary Displaced and bound down in the Cul-de-sac by Adhesions (Skene) . 444 

268. Vaginal Exploration of Pelvis. Posterior Cervical Fold Exposed (Pryor) . 467 

269. Posterior Incision (Pryor) 468 

270. Fingers Tearing Incision (Pryor) 469 

271. Diagram of Speculi in position in Opening (Pryor) 469 

272. Viewing Pelvis through Posterior Incision (Pryor) 470 

273. Uterine Appendages brought into Opening (Pryor) 471 

274. Diagram of Incisions for Treatment of Acute Pelvic Inflammations (Baldy) . . 481 

275. Drainage of Pelvic Abscess from the Vagina (Baldy) 488 

276. Abscess-sacs opening into the Bowel ; opening obliquely above and below 

the level of the sac (Baldy) 489 

277. Showing Multiple Abscess-cavities in a case of Pyosalpinx, demonstrating 

the uselessness of the treatment by tapping and drainage (Baldy) . . . 491 

278. Ligation by Figure-of-eight Ligature of the Fallopian Tube and Ovary 

(Baldy) 498 

279. Stump after removing Ovary, showing double ligation of Ovarian artery 

(Baldy) 501 

280. Vaginal Hysterectomy, Opening Posterior Cul-de-sac (Martin) 503 

281. Vaginal Hysterectomy, Diagram of Incisions (Pryor) 504 

282. Vaginal Hysterectomy, Clamps on Uterine Arteries (Pryor) 505 

283. Vaginal Hysterectomy, Fundus dragged down between Bladder and Cervix 

(Pryor) 506 

284. Vaginal Hysterectomy, Clamp on Right Ovarian Artery (Pryor) 507 

285. Vaginal Hysterectomy, Clamp on Left Ovarian Artery (Pryor) 508 

286. Vaginal Hysterectomy, Uterus removed by Splitting (Pryor) 511 

287. Vaginal Hysterectomy, Instruments necessary ■ 512 

288. Gravid Fallopian Tube at die Tenth Week, showing complete occlusion of 

the ostium (Bland Sutton) 521 

289. Diagrammatic Section of Fallopian Tube, representing the two directions of 

rupture in tubal pregnancy. A, into the peritoneal cavity (Tait) . . . 522 

290. Ibid. B, between the folds of the broad ligament (Tait) 522 

291. Transverse Section of the Pelvis of a Woman, with an Embryo and Placenta 

of the Fourth Mouth of Gestation occupying the Right Broad Ligament 

(Hart) 524 

292. Tubo-uterine Pregnancy (Bland Sutton) 525 

293. Diagrammatic Representation of Interstitial Tubal Pregnancy at the time of 

Rupture (Tait) 526 

294. Pregnant Fallopian Tube laid Open, showing fetus killed by hemorrhage 

into its membranes, but without the escape of the fetus from the tube 

(Tuttle and Cragin) 527 

295. Apoplectic Ovum, or Tubal Mole (natural size) (Bland Sutton) 528 

296. Decidua expelled from the Uterus in a case of Ectopic Gestation (Tuttle and 

Cragin) 533 

297. Decidua in situ ; fibroid uterus removed at the time of operation for ruptured 

ectopic gestation (Tuttle and Cragin) 534 

298. Photomicrograph of a Section of Decidua in a case of Ectopic Gestation, 

showing the large decidual cells (Tuttle aud Cragin) 535 



xx LIST OF ILLUSTRATIONS. 

FIG. PAGE 

299. Photomicrograph of Chorionic Villi, found in the tube of a case of Ectopic 

Gestation (Tuttle and Cragin) 538 

300. Tubal Rupture in the case of an Ectopic Gestation (Tuttle and Cragin ) . . 540 

301. Horizontal Section of the Abdomen immediately above the Crests of the Ilii 

(Savage) 544 

302. Uterus, Ovary, Fallopian Tube, Broad Ligament, and its Contents (Savage) . 546 

303. Section of Ovary 547 

304. Typical Corpus Luteum, fifteenth day from the beginning of menstruation 

(Leopold) 547 

305. Freshly-ruptured Follicle, twenty days after the beginning of the last 

menstruation (Leopold) 547 

306. Transverse Section of the Fallopian Tube of a Macaque Monkey (Bland 

Sutton) 548 

307. Recess of the Tubal Mucous Membrane of the Panolian Deer (Bland Sutton) . 549 

308. Transverse Section of the Human Fallopian Tube (Schenck) 550 

309. Diagram of the Structures in and adjacent to the Broad Ligament (Doran) . 558 

310. Broad-ligament Cyst, Fallopian Tube, and Ovary (Baldy) 559 

311. Cyst of the Organ of Morgagni (Baldy) 560 

312. Large Ovarian Cyst, weighing 149 pounds (N. Y. Med. Journ.) 562 

313. Proligerous Glandular Ovary and Cyst of areolar appearance (Pozzi) .... 563 

314. Multilocular or Glandular Cystoma (Montgomery) 564 

315. Portion of an Ovarian Adenoma, showing the varieties of Loculi (Bland 

Sutton) 565 

316. Calcified Corpus Luteum (Williams) 566 

317. Dermoid Cyst containing long red hair, removed from a light-haired woman 

aged 44 years (Montgomery) 567 

318. Calcified Fibroma of the Ovary (Williams) 569 

319. Showing the Structure of Calcified Fibromata (Williams) 570 

320. Fatty Abdominal Wall simulating an Ovarian Cyst (Baldy, from photograph 

in possession of Dr. Robert Hamill) 588 

321. Triple Interlocking Ligature ; the threads inserted (Greig Smith) 599 

322. Triple Interlocking Ligature ; the threads interlocked ready for tying (Greig 

Smith) 599 

323. Triple Interlocking Ligature, tied (Greig Smith) 599 

324. Cystoscope 608 

325. Conical Dilator 609 

326. Suction Apparatus 609 

327. Mouse-toothed Forceps 610 

328. Ureteral Searcher 610 

329. Long Flexible Ureteral Catheter 610 

330. Metal Ureteral Catheter 610 

331. Use of Cystoscope in Knee-chest Position (Kelly) 011 

332. Use of Cystoscope in Elevated Dorsal Position (Kelly) 612 

333. Examination of Urethra for Pus (Kelly) 615 

334. Pelvic Portion of the Ureter viewed from below (Kelly) 616 

335. Pelvic Portion of the Ureter viewed from above (Kelly) 617 

336. Course of the Ureters marked on the Abdomen (Kelly) 618 

337. Urethral Diverticulum containing pus and residual urine (Kelly) 626 

338. Uretero-ureteral Anastomosis (Baldy) 659 

339. Uretero-vesical Implantation (Baldy) 660 

340. Catheterization of Both Ureters (Kelly) 667 

341. Sutures in place for the Repair of Ventral Hernia (Baldy) 692 



LIST OF PLATES. 



PLATE OPPOSITE PAGE 

I.-Fig.l. Median Section of the Pelvis j (g) Frontispiece. 

Fig. 2. Dissection of the Perineum J 

II. — Fig. 1. Dorsal Position for Pelvic Examination : faulty (Baldy) .... 18 

Fig. 2. Dorsal Position for Pelvic Examination : faulty (Baldy) .... 18 

III. — Fig. 1. Dorsal Position for Pelvic Examination: correct (Baldy) ... 20 

Fig. 2. Knee-chest Position (Baldy) 20 

IV.— Fig. 1. Left Lateral or Sims's Position : front view (Baldy) 22 

Fig. 2. Left Lateral or Sims's Position : back view (Baldy) 22 

V. — Patient in Trendelenberg's Position on Krug's Frame: side view (Baldy) . 24 

VI. — Patient in Trendelenberg's Position on Krug's Frame : front view (Baldy) 26 

VII.— Bimanual Palpation of the Pelvis (Byford) 28 

VIII. — Fig. 1. Exposure of the Cervix through Sims's Speculum (Byford) . . 36 

Fig. 2. Simon's Position, showing Use of Eetractors (Byford) 36 

IX. — Operating-room of the Gyneceau Hospital prepared for an operation 

(Baldy) 46 

X. — Leg-holder applied with the Patient in the Dorsal Position (Baldy) . . 58 
XL — Microscopic View of Menstrual Fluid at different periods of Menstru- 
ation (Pouchet) 70 

XII. — Pseudo-external Bilateral Hermaphrodism (Krug) 120 

XIII. — Hypertrophy of the Nymphse, or Hottentot Apron (Billroth and Leuke) . 152 

XIV.— Fig. 1. Hypertrophy of Right Labium Majus (Baldy) 154 

Fig. 2. Hypertrophy of Right Labium after two weeks' treatment 

(Baldy) . . ." 154 

XV. — Hypertrophy of the Skin about the Vulva and Anus (Baldy) 156 

XVI.— Distended Vulvo-vaginal Gland (Byford) 158 

XVII. — Repair of Laceration of the Cervix Uteri (Penrose) 236 

XVIII. — Removal of Carcinoma of the Uterus by the Use of the Galvano-cautery, 

after the Method of Byrne (Dickinson) 376 

XIX. — Extra-peritoneal Treatment of the Stump following Hysterectomy (Baldy). 406 

XX. — Fig. 1. Supra-vaginal Amputation of the Uterus; first step (Baldy) . . 408 

Fig. 2. Supra-vaginal Amputation of the Uterus; second step (Baldy) . 408 

XXI. — Fig. 3. Supra-vaginal Amputation of the Uterus; third step (Baldy) . 410 

Fig. 4. Supra-vaginal Amputation of the Uterus ; fourth and final step 

(Baldy) 410 

XXII. — Fig. 1. Arterial Blood-supply of the Uterus and Adnexa (Hart) . . . . 412 

Fig. 2. Venous Blood-supply of the Uterus (Hart) 412 

XXIIL— Fig. 1. Total Abdominal Hysterectomy; first step (Baldy) 414 

XXIV.— Fig. 2. Total Abdominal Hysterectomy; second step (Baldy) 416 

Fig. 3. Total Abdominal Hysterectomy ; third step (Baldy) 416 

XXV. — Fig. 4. Total Abdominal Hysterectomy ; vaginal opening closed by 

sutures (Baldy) 418 

Fig. 5. Total Abdominal Hysterectomy ; vaginal opening closed by 

gauze packing (Baldy) 418 



xxii LIST OF PLATES. 

PLATE OPPOSITE PAGE 

XXVI. — Intraligamentous Fibroid ; front and back views (Baldy) 420 

XXVII. — Pyosalpinx and Ovarian Abscess (Baldy) 442 

XXVIII. — Fig. 1. Vaginal Hysterectomy with Clamps. Single-clamp Operation 

(Baldy) 502 

Fig. 2. Vaginal Hysterectomy with Clamps. Multiple-clamp Opera- 
tion ; first step (Baldy) 502 

XXIX. — Fig. 3. Vaginal Hysterectomy with Clamps. Multiple-clamp Opera- 
tion ; second step (Baldy) 506 

Fig. 4. Vaginal Hysterectomy with Clamps. Multiple-clamp Opera- 
tion ; third and final step (Baldy) 506 

XXX. — Fig. 1. Vaginal Hysterectomy with Ligature; first step (Baldy) . . 512 
Fig. 2. Vaginal Hysterectomy with Ligature; second step (Baldy) . 512 
XXXI. — Fig. 3. Vaginal Hysterectomy with Ligature ; third step (Baldy) . . 514 
Fig. 4. Vaginal Hysterectomy with Ligature ; fourth and final step 

(Baldy) ..." 514 

XXXII. — Combined Ectopic and Intra-uterine Gestation (Tuttle and Cragin) . 518 
XXXIII.— Full-term Fetus developed between the Folds of the Eight Broad 

Ligament (Tuttle and Cragin) 522 

XXXIV. — Tubal Abortion ; Membranes protruding from the fimbriated extrem- 
ity of the Fallopian Tube (Tuttle and Cragin) 526 

XXXV. — Tubal Abortion ; Placenta and Fetus protruding from the fimbriated 

extremity of the Fallopian Tube (Tuttle and Cragin) 528 

XXXVL— Intra-ligamentary Broad-ligament Cyst (Baldy) 558 

XXXVII. — Dermoid Cyst laid open and showing the various contained structures 

(Baldy) 568 

XXXVIII.— Course of the Ureters and Pelvic Blood-vessels (Kelly) 616 



AN AMERICAN 

TEXT-BOOK OF GYNECOLOGY. 



EXAMINATION OF THE FEMALE PELVIC ORGANS. 



In making an examination for disease of the female pelvic 
organs the first thing for a physician to do is to acquire the con- 
fidence of the patient, it being presupposed that he possesses an 
adequate knowledge of all known physiological and pathological 
conditions of these organs. An untidy office, a dirty hand, a care- 
less manner, and a rough demeanor are as inimical to his success as 
is the lack of knowledge and training in gynecology. The fear of 
the patient that she may become infected by filth, be hurt by 
manipulation, or be neglected through carelessness is often suf- 
ficient to deter her from undergoing a treatment which is, under 
the most favorable circumstances, a distasteful and onerous under- 
taking. He should remember that the patient comes prepared to 
sacrifice all preconceived notions of modesty to his dictum, and 
does so with the full belief that he possesses the refinement of a 
gentleman and the acquirements of a scholar. 

He must not be impatient if she commences talking first of other 
parts of the body, avoids complete explanations of certain symp- 
toms, or is a little dilatory in submitting to the necessary examina- 
tions. On the other hand, he should never abate in his deference 
to a woman who, having once submitted to gynecological treatment, 
conducts herself toward him with that familiarity and trustfulness 
which the sacredness and dignity of his calling inspire. 

If she chooses to talk of her ailments, it is well to listen atten- 
tively to the recital until satisfied that they are of pelvic origin, 
when the physician may begin by appropriate questions to obtain a 
systematic description of her case. The data should be entered in 



18 AN AMERICAN TEXT-BOOK OE GYNECOLOGY. 

a case-book in the following order : Name ; age ; whether married 
or not, and if so, how long and whether more than once ; number of 
confinements, with dates of first and last, and number and dates of 
abortions ; her occupation and habits, whether sedentary or active ; 
age of first menstruation, and how regular since then ; whether 
menstruation is painful or not; when the pain commences and 
stops, and where it is felt and what its character ; the length of 
time the flow lasts, whether profuse and clotted, or scanty, or pro- 
longed by recurrence after cessation for a few hours or days; 
amount and character of. discharge from vagina between the men- 
strual periods ; the condition of nutrition as seen by the appear- 
ance of the tongue, conjunctiva, and skin; and the state of the 
nervous system. 

Having obtained these facts, and others that may be acquired 
during the questioning, he will have a foundation upon which to 
construct an accurate diagnosis. The patient may be allowed to 
relate her special symptoms, or he may inquire for the various 
ones that accompany the disorders under consideration, or he may 
ask for special symptoms of whatever disease the knowledge 
already acquired leads him to expect. 

He should always carefully differentiate between conditions 
which are of such gravity and long standing as to call for an exam- 
ination, and those which are temporary and may be relieved by 
general treatment. 

The functions of the kidneys, bladder, bowels, and rectum should 
be inquired into, as well as the effect of exercise or quiet upon her 
symptoms. A qualitative and quantitative analysis of the urine 
and an examination of the heart should be made in very fleshy or 
anemic patients, and also in those presenting symptoms referable 
to the abdomen and chest. 

Preparations for an Examination. 

Although the examination in most cases can be made without 
preparation of the patient and at the first interview, yet when there 
is any difficulty in arriving at an accurate diagnosis it is well to 
have her return upon another occasion properly prepared. Such 
preparation should consist in mild purgation upon the previous day, 
and a soapsuds enema on the morning of the examination. The 
diet on the same day should be light, and the bladder be evac- 
uated immediately before the examination. 



r 



EXAMINATION OF THE FEMALE PELVIC ORGANS. 19 

When the examination is made at the patient's house, a sofa 
without arms may be drawn near a window, and stools placed at 
the end for the feet, or a table may be used, with chairs for the feet. 
If more convenient, the patient may sit on a pillow placed at the 
edge of a bed, and may lie back with her feet on chairs placed two 
feet apart. The corset and waist-bands should be loosened. 

At the office the physician should be provided with a gyneco- 
logical table, or a chair of simple construction that allows of elevat- 
ing or depressing the shoulders or that can be made perfectly flat. 
Stirrups should be attached, so arranged that the feet can be ele- 
vated, depressed, or separated to any required extent, and held near 
the body or some distance away. 

The end of the chair or table should be toward and near a window. 
Between it and the window, and at the right hand of the operator 
as he sits facing the chair, should be placed a cabinet or stand with 
drawers for holding instruments, medicine, and appliances. A sta- 
tionary washstand should be near. By thus having everything con- 
venient, one works easily and rapidly and saves time to himself and 
trouble to the patient. 

A sheet should always be at hand to throw over the patient as 
she lies down. 

Position of Patient. 

For ordinary pelvic examinations the patient should be put on 
her back, with the hips at the edge of the chair or table, facing the 
window, the feet being supported in the stirrups on a level with her 
hips, and far enough apart to allow ample space between them for the 
physician to work, and far enough from the patient's body for her 
comfort. Generally the head and shoulders should be slightly 
higher than the hips. In special instances we may elevate the 
shoulders and feet in order to secure greater abdominal relaxation. 
This is called the dorsal position. It is the best position for the 
digital and bimanual examinations, and is often employed for 
ordinary treatment on account of its convenience. 

A digital examination may be made in the Left Lateral or Sims' 
position. The patient is placed upon her left side with the hips at 
the left-hand corner of the table, and both knees drawn up as far 
toward the chest as possible. The left arm should be drawn back 
behind her, and the right or upper knee drawn a little farther up 
and over the left until it almost touches the table, in order that the 



20 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

patient may be tipped on her left breast. Care must be taken to 
keep the knees well flexed. It is better to have the foot of the 
table a. little higher than the head. 

This position has the disadvantage that the upper pelvic organs 
are not so easily reached as in the dorsal, either for a digital or a 
bimanual examination. For inspection of the vaginal fornices, 
tamponment of the vagina, and operations upon the cervix and 
anterior vaginal wall it is in America and in England the favorite 
position. 

The Knee-chest position requires that the patient kneel near the 
edge of the table, and, with arms thrown back and head turned to 
one side, allow the chest to sink down on the table just in front of 
the knees. The thighs are flexed on the abdomen. The chest is 
lower than the pelvis, and when air is allowed to enter the vagina 
the uterus sinks away from the vaginal entrance. This peculiarity 
is shared by the lateral position. For altering the position of the 
pelvic organs and for vaginal tamponment this position is useful, 
but it is not desirable for ordinary examinations. 

The Trendelenburg position is obtained by placing the patient 
on her back and raising the lower end of the table, thus elevating 
the pelvis and thighs and allowing the legs to fall over the edge. 
Its chief advantage is for operations upon the pelvic organs by 
abdominal section. The abdominal viscerae recede from the pelvis, 
and leave the pelvic peritoneal cavity open to inspection through 
the abdominal incision. It is not often employed for examinations 
per vaginam. The accompanying cuts illustrate this position as 
obtained by the use of Krug's frame, which can be fastened to any 
table. 

The Upright position, which gives information as to the position 
of the pelvic organs while the patient is up and about her duties, 
is chiefly useful in determining the extent of displacements. In this 
position the patient stands against some supporting object with the 
feet separated, while the physician kneels on one knee in front of 
her. 

Methods of Examination. 

There are three methods of examination : the ocular, the manual 
or digital, and the instrumental. 

Ocular Examination. — If the symptoms point to a disease of the 
vulva or vagina, the patient is placed in the dorsal position, covered 



EXAMINATION OF THE FEMALE PELVIC ORGANS. 21 

with a sheet, the skirts pushed up over and beyond the knees, and 
the sheet pushed back between the limbs over the mons Veneris, so 
as to expose the vulva and perineum. The external parts and 
vaginal entrance are then inspected, and the finger is introduced 
as far into the vagina as necessary. 

Digital Examination per Vaginam. — For this examination the 
best position is the dorsal. If the symptoms point to intrapelvic dis- 
ease, it is best not to expose the patient at first, but pass the partly- 
closed hand under the sheet and along the inside of the thigh 
until the dorsal surfaces of the fingers gently touch the perineum 
or vulva. The position of the labia majora will be immediately 
recognized and any abnormal condition detected. The dorsal sur- 
face of the index finger is gently pushed between them until 
arrested in the vaginal entrance. The finger is then extended, 
and the finger-end glides over the perineum into the vagina. 
Any peculiarity of the hymen, obstruction from a vaginal tumor 
or prolapsed organs, or gaping of the parts from relaxation or 
laceration will be forced upon the attention, either by the difficulty 
or the unusual ease of the manoeuvre. When there is much devia- 
tion from the normal, the parts may be exposed to view at once, 
otherwise the ocular inspection and external manipulation are better 
left until the internal examination has been made. 

After the finger has entered the vagina the posterior wall, or 
rectum which lies under it, will attract attention if abnormal. If 
not, the finger is turned, palmar surface upward, and slight pressure 
against the anterior vaginal wall is made to detect enlargement, dis- 
placement, or tenderness of the urethra and bladder or organs above 
them. 

Having thus gone over the parts about the vaginal entrance, the 
objective point should always be the cervix uteri. It should be 
found from two and a half to three inches from the pubic arch, so 
that when the finger touches the cervix and is raised up against the 
anterior vaginal wall, the subpubic ligament will press against the 
finger between the second and third joints. The finger-end is swept 
around the cervix to discover if the fornices are diseased or en- 
croached upon by surrounding abnormal tissue. Very often one 
lateral fornix is narrower than the other, and by pressing straight 
outward laterally the distance of the pelvic wall will be found to 
be less on that side, and lateral displacement will be detected. 

The size, shape, and consistency of the cervix and the position 



22 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

and shape of the external os — in fact, all changes except in color — 
are discovered in this way, and the diagnosis usually made before 
the speculum is used. The finger-end should press well up in 
front, behind, and to the sides of the cervix, in search of an ante- 
or retroverted or flexed fundus, adherent ovary or pelvic exudate. 
By pressing well back and laterally we can sometimes catch an 

Fig. 1. 




Normal Position of the Uterus. 



enlarged or prolapsed ovary against the pelvic walls. The right 
hand should be used for palpating the right side of the pelvis, and 
the left hand for the left side. 

Vaginal palpation of the ureters is easily executed in the dorsal 
position, and should always be practised. They are much more 
easily felt than might be supposed, because they are situated at the 
dividing-line between the soft, elastic parametric connective tissue 
and the firmer peripheral fatty connective tissue, at the lateral and 
front parts of the pelvis. The finger-end, pressed very gently up- 
wind in front of the cervix and drawn toward the pubes, feels, about 
half an inch in front of the cervix, the posterior edge or base of the 
trigone of the bladder, and then conies upon the firmer part of the 
anterior vaginal wall under the trigone. By repeating this forward 
and upward hooking motion of the finger-end, getting a little more to 



EXAMINATION OF THE FEMALE PELVIC ORGANS. 23 

one side each time, the same cord-like edge of the firmer tissue repre- 
senting the ureter can be traced laterally and backward toward the 
sacro-iliac synchondrosis. During the earlier months of pregnancy, 
and in the presence of disease of the ureters, they are easily traced as 
large, somewhat tense cords, backward and outward to the pelvic walls. 

Two fingers may be used in the vaginal examination when it is 
desirable to reach farther than is possible with one. One finger is, 
however, generally to be preferred, because the touch is freer and 
more delicate and the inconvenience less to the patient. 

By hooking two fingers backward toward the coccyx, and then 
strongly outward toward the anus, the anterior wall of the rectum 
may be everted, and its condition, as well as that of the anal rim, be 
revealed to the eye. This manoeuvre is somewhat painful, and not 
always well tolerated by the patient. The finger and thumb of the 
other hand may with advantage push the tissues behind the anus 
backward, so as to increase the anal distension. 

Digital Examination per Rectum. — In virgins, or other patients 
in whom the posterior pelvic wall cannot be reached or in whom 
conditions in the posterior half of the pelvis cannot be diagnosed 
through the vagina, rectal indagation gives valuable information. 

As the rectum is dry and sensitive, the forefinger should be 
abundantly smeared with vaseline or some other unirritating fat, 




Digital Eversion of the Rectum. 

and introduced, palmar surface down, in a forward direction until 
the finger-end has passed over the edge of the levator ani (rectal 
promontory), and then flexed a little until the whole finger is 



24 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

introduced. Then it should be straightened and slowly rotated 
until the palmar surface can be used to palpate the anterior wall. 
Before rotating it is well to touch the coccyx, or even grasp it be- 
tween the finger within and the thumb without. Fracture, anky- 

Fig. 3. 




Palpation of the Coccyx. 

losis, unusual mobility, abnormal sensitiveness, or dislocation can 
be detected. 

As soon as, or even before, the finger is rotated, the cervix, or, 
if there be retroflexion, the fundus uteri, will usually be detected 
within easier reach than per vaginam. The finger is then pressed 
on under the retroflexed or retroverted fundus, and readily detects 
an ovary or tube in the cul-de-sac of Douglas or any induration at 
the uterine horns. The retroverted fundus can be pressed upward, 
and any unusual resistance or bands of adhesions recognized. 
Appendages or tumors adherent to the lateral and posterior walls 
of the pelvis are easily felt. The connective-tissue fibres running 
from the cervix to the pelvic walls usually shut off the upper part 
of the pelvis from observation. In order to reach these higher 
parts the finger-end is pushed along against the sacrum, until it 
passes through a constricted part of the gut and emerges up behind 
the uterus, and between and over the sacro-uterine ligaments. It 
then has access to the lower abdominal cavity and can palpate the 
parts with distinctness. Usually, however, the anus is too sensitive 
or the finger too short to allow of a satisfactory exploration of this 
kind, and two fingers with the aid of anesthesia will be required. 



EXAMINATION OF THE FEMALE PELVIC ORGANS. 25 

The half or whole hand can be passed into the rectum and a com- 
plete intrapelvic exploration made. This, however, is apt to injure 
the sphincter ani and rectum, and is generally unnecessary, for the 
bimanual examination with two fingers in the rectum gives us the 
same information without it. 

An accurate knowledge of anatomy, and a little practice, will 
enable us to palpate and recognize the pyriformis muscle and the 
sacral plexus of nerves lying upon it, the small sacro-sciatic liga- 
ment, the greater sciatic foramen, the various pelvic arteries, etc. 

With the index finger in the rectum and the thumb in the vagina 
the cervix, or even the retroverted uterus, may 'be grasped and its 
size, mobility, and relations determined. 

Fig. 4. 




Rectal Palpation of the Uterus drawn down by a Vulsellum Forceps. 

The fundus uteri and adjacent tissues may be rendered more 
accessible to the rectal finger by drawing the cervix to the vaginal 
entrance with a vulsellum forceps. (Fig. 4.) 



The Bimanual Examination. 
In order to complete our information with regard to the pelvic 
organs it is necessary to make use of the bimanual examination. 
To do this we first inform ourselves of the position of the cervix, 
etc., by ordinary vaginal indagation, after which the other hand, 
previously placed over the pubes, presses gently, but with increasing 
firmness, upon the abdominal walls, sinking the finger-tips a little 



26 



AN AMERICAN TENT-BOOK OF GYNECOLOGY. 



deeper with each inspiration of the patient, until the uterus is felt 
to descend upon the vaginal finger (Fig. 5). The uterus is 
thus brought down until its anterior and lateral surfaces can be pal- 




Bimanual Palpation of the Uterus. 

pated through the anterior vaginal wall. By a series of gentle pushes 
from above and below the position, mobility, size, and shape of the 
uterus can be ascertained. Great gentleness must be observed not 
to hurt the patient nor to displace the organ before its position is 
determined. In case the fundus is not felt, the outside finger should 
be pressed into the abdominal walls a little higher up. When the 
abdominal walls are lax or the patient anesthetized, they can be 
depressed until the sacral promontory is felt. Then the fingers are 
brought downward toward the pubes until they are felt by the vaginal 
finger to touch and move the uterus. Under an anesthetic the retro- 
verted uterus can be picked up between the fingers bimanually and 
replaced, or if adherent its mobility tested. 

The uterus can be retroverted by hooking the cervix forward with 
the vaginal finger, and sinking the external fingers over the pubes 
and pressing toward the sacral promontory, and thus the posterior 
surface brought within reach. 

By pressing well down beside the uterus until the fingers of both 



EXAMINATION OF THE FEMALE PELVIC ORGANS. 27 

hands touch with only the abdominal walls between, we may palpate 
the ovaries and tubes. If the ovaries are not easily recognized, the 
fingers of the two hands should be kept in contact and brought 
toward the pubes and Poupart's ligament, alongside the anteverted 
uterus, from the cervix toward the fundus. The first decided infor- 
mation is given by the sudden slipping of the ovarian ligament 
between the finger-ends, like a tense cord stretched across the field. 
By repeating this manoeuvre a little further to the side, we come 
against the ovary, which if small may merely feel like a fusiform 
enlargement of this cord. The ureter may give a sensation similar 
to the ovarian ligament, but it feels less tense and is easily traced to 
the side of the pelvis by the vaginal finger, and thus differentiated. 




Bimanual Rectal Palpation of the Pelvis. 

The round ligament feels like a relaxed cord, and is only felt indef- 
initely. The normal Fallopian tube gives only a very indefinite 
sensation, as of a fold of membrane. When enlarged and occluded 
it usually curves backward over the ovary, and feels somewhat like 
a small fusiform or club-shaped tumor tapering toward the horn of 
the uterus. Extensive adhesions usually cause a matting together 



28 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

of the appendages in a roundish or irregular-shaped mass, but little 
movable itself, and partially fixing the uterus. 

With one or two fingers in the rectum the external (abdominal) 
and vaginal fingers may be approximated behind the uterus, and 
the condition of the posterior and upper parts of the pelvic cavity 
quite accurately ascertained. 

Fig. 7. 




Bimanual Recto-vaginal Palpation of the Uterus. 

With a finger in the rectum and the thumb in the vagina grasp- 
ing the cervix, while the fingers and thumb of the other hand grasp 
the fundus through the abdominal walls, the consistency, flexibility, 
size, mobility, and relations of the uterus can be appreciated with 
a surprising degree of ease. The displaced uterus can be grasped 
and replaced in this way. 

In order to become an expert diagnostician the gynecologist 
should accustom himself to use either hand in the vagina or over 
the abdomen, that he may be able to reach both sides of the pelvis. 

The bimanual examination of the uterus is of the utmost import- 
ance in the diagnosis of pelvic tumors. Ovarian tumors of mode- 
rate size are often entirely overlooked when they lie over and behind 



EXAMINATION OF THE FEMALE PELVIC ORGANS. 29 

the uterus, because they are not within reach of the vaginal finger. 
When, however, the abdominal walls are pressed down into the 
pelvis, not only is the tumor discovered, but its size, consistency, 
mobility, and the length of its pedicle are often recognizable. Tu- 
mors of the uterus can be mapped out in this way and their size 
and relations to the organ determined. Long-continued practice is 
necessary to render the beginner expert in these matters. 

Digital and Bimanual Examination in the Lateral Position. — 
Similar examinations may be made in the left lateral position with 
the left hand in the vagina or rectum and the right hand over the 
abdomen, but hardly as satisfactorily as in the dorsal position. 
However, it gives one a better comprehension of the mobility and 
relationship of the organs to examine in both positions and compare 
results. 

Anesthesia. 

In many cases, even after a thorough evacuation of the bowels, 
the tension of the abdominal walls, the sensitiveness of the organs, 
or the complications in the pathological conditions render a satis- 
factory examination impossible. In such cases the administration 
of an anesthetic not only renders all of the methods described 
available, but the relaxation of the tissues enables us to employ 
them without force and without fear of causing that feeling of sore- 
ness and discomfort that sometimes follows a thorough examina- 
tion without the anesthesia. When there is the slightest doubt. as 
to the pathological condition, the patient should always be anes- 
thetized for the examination. 

Examination of the Vaginal Entrance. 
An ocular examination of the vaginal entrance will reveal the 
condition of the superficies, but it will be incomplete unless aided by 
the educated touch. If a laceration is mostly external, its extent 
is much better appreciated if the finger be introduced into the anus 
and the thickness of the perineal body palpated between the finger 
and thumb. The scar-tissue may be blanched and made plainly 
visible by pulling out the tissues with the finger in the anus, so 
as to stretch the perineal body. If the fourchette be intact, the 
extent of internal deficiency due to laceration may be measured by 
pressing the finger down along the pubic rami within the vulvo- 
vaginal entrance. Normally, the levator vaginae so stretches around 



30 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

the vaginal entrance as to prevent palpation of the pubic ramus 
except by quite firm pressure. When the fibres of this muscle are 
torn, the anterior sulci beside the urethra are widened and the bony 
surfaces easily felt. The vaginal entrance, instead of being ovoid 
or roundish, is bounded posteriorly by the V-shaped edge of the 
levator ani, with the rectum passing over it filling the angle and 
leaving a sulcus on either side. When the transversus perinei is 
torn, the finger readily traces the bony surfaces of the pubic rami 
down to a level with the anus on the side of the tear. When the 
sphincter is torn, the anterior edge of the anus is thin and cicatricial, 
and the dark-red edges of the rectal mucous membrane are visible, 
often giving an ulcerated appearance to the novice. 

Instrumental Examination. 

The Uterine Sound. — Various forms of uterine sounds have been 
devised. The most serviceable ones are Simpson's and Sims'. 
They are about 30 cm. long, and from 2 to 3 mm. in diameter, 
with a slightly enlarged bulbous end. The end toward the handle 
is somewhat thicker. Simpson's sound, formerly stiff, is now made 
of a somewhat flexible metal, and has a mark indicating the normal 
length of the uterine cavity (2i inches, or 7 cm.) ; Sims' sound is 
a trifle lighter and much more flexible than Simpson's. They 
should be made entirely of metal. Jenks' spiral sound and Thomas's 
whalebone or hard-rubber probe are useful forms, because they 
adapt themselves to the curve of the uterine canal. On account 
of their elasticity they do not retain its curve. Uterine probes 
resemble the sound in shape, but are more delicate, and are useful 
in exploring a distorted uterine cavity. 

To Introduce the Sound, the cervix should be located with the 
index finger, and the sound, about seven centimeters from its point, 
bent at. an angle of about forty-five degrees, and introduced along the 
palmar surface until the bulbous end passes into the cervical canal. 
By depressing the handle and, if necessary, drawing the cervix 
slightly forward either with the finger, the sound, or a tenaculum, 
the instrument easily passes to the fundus. No force must be used, 
but the curve of the sound changed again and again, if necessary, 
until it passes easily. By giving it a sharper curve with a coun- 
ter-curve near the handle we often succeed better in making it pass 
a more acute flexure. 

The digital or bimanual examination will generally enable us to 



EXAMINATION OF THE FEMALE PELVIC ORGANS. 31 

determine what the angle or curvature of the sound must be. A 
narrowness of the internal os, due to uterine flexion or spasmodic 
contraction, sometimes interferes with the passage of the sound and 
may render it painful. In such cases much force should not be 
used, but the attempt postponed until an examination by the 
speculum is made. 

The Uses of the sound consist in ascertaining the patency of the 
uterine canal, its direction, length, size, and sensitiveness. In con- 
nection with the abdominal palpation we can also determine in what 
part of the uterus the enlargement or tumor is located. The mobility 
of the uterus and its connection with the pelvic organs, or its inde- 
pendence of them, can sometimes be more accurately determined 
than by the ordinary bimanual examination alone. 

The Dangers in the use of the sound are the introduction of 
septic matter into the uterus, the lighting up of an old endometritis 
or pelvic inflammation, and the perforation of the uterine walls. 

It is better, when practicable, to use the sound through the specu- 
lum after the vaginal foruices and cervix have been wiped out dry 
with absorbent cotton, and then swabbed out with a 5 per cent, 
solution of carbolic acid. When, however, it is necessary to use 
the sound without the speculum, the vagina should be thoroughly 
douched out with a 1 : 2000 solution of bichloride of mercury. The 
sound should be kept scrupulously clean, and be dipped in a 5 per 
cent, carbolic solution the last thing before its introduction. The 
spiral sound should be boiled after use in every septic case, and 
only used when the other sound does not give the information 
sought. 

The softened uterine body has been perforated many times by 
the sound without serious results. In such cases the instrument 
passes almost its entire length, and can be felt bimanually through 
the abdominal walls. The only danger consists in carrying sepsis 
into the peritoneal cavity — not a very serious one if the proper 
antiseptic precautions have been takem 

It has occasionally happened that the sound has passed into a 
Fallopian tube. This is especially liable to occur in a uterus bicor- 
nis, and does no harm unless force is used or sepsis introduced. 
It is best never to use a sound where it is possible to gain the 
desired information by other means. In all but exceptional cases 
this may be easily accomplished, and consequently the use of the 
sound has in great part been dispensed with. 



32 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



The Uteeine Elevator. 

Another important, although at the present clay infrequent, use 

of the sound is as a uterine elevator to replace the retroverted uterus. 

It has been variously modified, so that the angle can be changed 

Fig. 8. 



QBffl 




Sims' Uterine Elevator. 

by a screw or appliance on the external end. Such modifications 
are, however, objectionable, in that it is impossible to determine 
just how much force is being used, and whether or not the endo- 
metrium and uterine walls are being injured. By giving the uter- 
ine sound a proper curve and sweeping the outer end around a 
circle, the fundus can be elevated and the amount of resistance 
easily gauged, and the use of much force avoided. 

Fig. 




EXAMINATION OF THE FEMALE PELVIC ORGANS. 33 
Fig. 10. 




Byford's elevator, made by cutting off the sound at its point of 




Byford's Uterine Elevator. 



emergence from the uterus and placing a finger-cap upon it at right 
angles, gives the requisite accuracy and delicacy of touch. It is 
introduced and the cap pushed in the direction opposite to that the 
fundus is to take. When the fundus rises high in the pelvis the 
finger readily slips into the cap and is held there by atmospheric 
pressure. The long axis of the sound and long axis of the finger 
are at right angles to each other, and thus the position of the fundus 
always known. 

The Speculum Examination. 
The methods already described will usually suffice for ordinary 
diagnosis, but when an ocular inspection, local treatment, or plastic 
operation becomes necessary, a speculum must be used. 



34 



AN AMERICAN TENT-BOOK OF GYNECOLOGY. 



The simplest and most nearly allied to a perfect exposure of the 
parts is obtained by the use of a perineal retractor, in the lateral or 
Sims' position. When the patient is sufficiently turned on the breast 
and the perineum drawn back, the uterus and anterior vaginal wall 
sink away from the outlet and leave all the interior of the vagina 
exposed to view except the part covered by the instrument. If the 
patient be tightly laced or not sufficiently turned on the chest, the 

Fig. 12. 




Action of Byford's Uterine Elevator. 

anterior vaginal wail will not be drawn far enough up behind the 
pubes. We may then have to use a depressor to push it out of the 
way. If we wish to get a closer view of the cervix, we can draw 
it nearer to the pubes by means of a tenaculum. This is also 
useful in steadying the cervix for the introduction of the sound. 
The uterine dressing forceps, of which a great variety have been 
devised, are invaluable in enabling us to wipe out the cervical mucus 
and disinfecting the vaginal fornices before using the sound. When 
the mucus is too thick and tenacious to be wiped off, we can coagu- 
late it by repeated applications of astringents or soften it with strong- 
alkaline solutions. For making uterine applications, uterine appli- 
cators and intra-uterine syringes have been devised. The applica- 
tors usually consist of a flattened piece of flexible metal, preferable 
silver, or a silver probe flattened on the end and without any bulb- 
ous or other enlargement. A small flat piece of common cotton is 
wound tightly around it, dipped into the solution, and passed into 



EXAMINATION OF THE FEMALE PELVIC ORGANS. 35 

the uterine cavity as far as desirable. Common cotton is preferable, 
as the medicines to be applied do not soak through it quickly, so as 

Fig. 13. 




Sims' Speculum Introduced. 



to corrode the instrument before it can be removed. The syringe 
is made of hard rubber, and is used by being introduced to the 
fundus of the uterus and the contents injected into the uterine cavity. 



Fig. 14. 



Uterine Applicator. 

Vaginal tampons are easily introduced and adjusted in the Sims' 
position, for the vagina is expanded and the uterus is well up in the 
pelvis. 

The Introduction of the Perineal Retractor requires some expla- 
nation. The double retractor, or Sims' speculum, is the one ordi- 
narily used. After throwing a sheet over the patient the clothes 



36 ^V AMERICAN TEXT-BOOK OF GYNECOLOGY. 

are pushed up, the edge of the sheet tucked under the right or upper 
thigh, and the lower one, unless covered hy the patient's drawers, 
is covered by a napkin. The speculum is grasped in the right hand 
with the index finger along the concavity of the blade, and pushed 
into the vagina with the convexity and handle toward the sacrum, 
while the labia are held apart with the fingers of the left hand. 
The end of the blade is passed well back toward the hollow of the 
sacrum, and the perineum drawn away from the urethra so as to 
open up the vagina. An assistant then grasps the shaft of the 
retractor in his right hand, the thumb resting against the under 
surface of the outer blade, and with the left hand holds the nates 
up to the edge of the speculum. The left forearm of the assistant 
should rest upon the patient's hip, while the right elbow and fore- 
arm rest against his own body. This ensures against unsteady 
traction and early tiring on the part of the assistant. 

The objection to the use of Sims' speculum in ordinary office 
practice is the necessity of having an assistant. Many ingenious 
modifications and appliances have been devised to retain the re- 
tractor, but as these require the use of a belt or shoulder-strap, their 
application is time-consuming and troublesome. 

On account of these objections the Sims speculum has not been 
able to displace the self-retaining bladed specula that are used in 
the dorsal position. For inspection of the cervix and the ordinary 
local treatment at the office the bivalve instruments answer quite 
well. Through them the mucus can be wiped out, the fornices dis- 
infected, the sound passed, the cervix dilated, intra-uterine applica- 
tions made, and tampons placed. 

Two or three sizes or varieties are requisite to enable one to fit 
all cases. Among the best is Goodell's. 

The cylindrical speculum, formerly so popular, is now seldom 
used in America, as the exposure is too limited and the space 
within it too cramped. Fergusson's is the one usually found in the 
stores. 

The right index finger first ascertains the position of the cervix, 
and is then held just within the vaginal entrance, while the thumb 
holds the right labium aside. The speculum is passed between 
the thumb and finger, with its upper blade laid diagonally on the 
right finger, until it passes into the vagina. As the speculum 
touches the vulva, the left middle finger should push the right 
Labium well outward to prevent hairs or folds of the labia being 



PLATE VIII. 
Fig. 1. 



"%.._ 





Exposure of the Cervix through Sims's Spec 
Fitt. 2. 









u 




Dorsal Position blowing use of Keiraetors. 



EXAMINATION OF THE FEMALE PELVIC ORGANS. 37 

dragged into the vagina. If such happens, a very slight sepa- 
ration of the blades of the speculum releases the parts. The 
instrument is then so turned that the lower longer blade lies 
flat against the perineum and is passed on under the cervix. As 
the blades are separated, the upper one comes up just in front of 
and exposes the cervix. With proper manipulation neither the 
sound nor tenaculum is ordinarily needed to bring the cervix within 
the field. The speculum should not be tightly closed when removed, 
for fear of pinching the labia or catching the hairs. 




Bivalve Speculum Introduced. 



The sound can ordinarily be passed into the uterus through 
the speculum without trouble, although in cases of anteflexion 
with a small cervix and vagina, the cervix will sometimes have 




Passage of tbe Uterine Sound, in Case of Anteflexion with Retroversion. 

to be hooked forward with a tenaculum. The greatest difficulty 
to the beginner consists in passing the sound in a case of anteflex- 
ion with retroversion. 



38 AN AMERICAN TEXT- BOOK OF GYNECOLOGY. 

This is, however, easily done by pressing the well-curved sound 
first toward the hollow of the sacrum, until arrested at the bend 
of the uterus, and then causing the handle to describe a semicircle, 
when the probe end will point upward ; it will then readily pass to 
the fundus. It often seems to the beginner as if the sound had 
passed through a spiral or corkscrew canal. The same manoeu- 
vres, reversed, may be employed for sounding a sharply-retroflexed 
uterus. 

In introducing tampons the cervix should be pushed in the 
direction it is to be held, and the tampons placed against or around 
it and held there by the forceps, until the speculum is partly with- 
drawn. "When more tampons are needed they may be introduced 
and held until the speculum is withdrawn over them also. In ordi- 
nary treatment it is best not to use too many large tampons, since 
they over-distend the vagina and weaken its walls. 

Examination in the dorsal position with vaginal retractors 
(Simon's method) is one of the most satisfactory methods, but 
usually requires the use of an anesthetic to display its advantages. 

A broad perineal retractor holds back the perineum, and nar- 
row ones keep the bladder or lateral vaginal walls out of the way. 
The cervix can usually be drawn down to the vulva by tenaculum 
forceps. Simon's retractors are seldom used in America on account 
of their cumbersomeness. Lighter modifications are more often 
employed. 

The speculum and perineal retractor are not, strictly speaking, 
instruments of diagnosis, for they reveal nothing that the finger 
cannot diagnose, except the color of the cervix and the character 
of the secretions issuing from its canal. Sims' speculum is best 
adapted for local treatment and for minor operations ; the bivalve 
speculum for local treatment. 

Dilatation of the Genital Tract for Examination. — It often hap- 
pens that a satisfactory examination is impossible on account of the 
narrowness of some portion of the genital tract. In virgins the 
hymen may not admit the fingers without great pain, and it may 
be necessary to make the first examination under anesthesia. In 
some cases we can succeed with local anesthesia by cocaine or by 
dilating the parts slightly and progressively at the first few sittings. 
We can sometimes introduce only the little finger (well lubricated) 
the first time. In two or three days the index finger may gain en- 
trance, and the next time the smallest speculum. When we succeed 



EXAMINATION OF THE FEMALE PELVIC ORGANS. 39 

in getting in the speculum, it should be allowed to remain a few mo- 
ments, then slightly expanded, and a small glycerin tampon pushed 
through it into the vagina and left for twenty-four hours. The next 
time a larger tampon should be left. After this the cervix may be 
exposed, and all difficulty will soon disappear. Similar manoeuvres 
may be made with the smallest-sized Sims' speculum. A vir- 
gin should, however, but rarely be examined. Should it become 
necessary, a rectal examination will usually answer all purposes, 
but if this is not found to be satisfactory, the patient should be 
first anesthetized. 

Very often a conical, flexed, or imperfectly developed cervix will 
prevent examination and treatment of the uterine cavity. In such 
cases the cervix should be drawn forward by a strong hook or vul- 
sellum forceps, and some form of tent or a dilator of small size 
gently forced into its canal. In some cases nothing can be made 
to enter without causing too much pain, except a slippery-elm tent 
but little larger than a crochet needle, whittled out of a fresh 
piece of slippery-elm bark, moistened in a 5 per cent, aqueous car- 
bolic-acid solution, and slightly crushed in the jaws of the dress- 
ing forceps to render it flexible. After two or three such treat- 
ments larger ones can be passed, and finally a small dilator or a 
delicate block-tin sound bent at a proper angle. We will then be 
able to explore the cavity with a small curette for softened mu- 
cous membrane, debris of malignant growths, etc. Schultze has 
recommended the introduction of a piece of sterilized lint or gauze 
into the vagina, and its removal in a few hours for the purpose of 
examining the secretions adherent to it. 

When a more extensive dilatation is required, the vagina and 
uterus may be thoroughly swabbed out with a 5 per cent, solution 
of carbolic acid or a 1 : 2000 solution of bichloride of mercury, and 
a long narrow strip of iodoform gauze pushed into the uterus until 
it fills the entire cavity and projects from the cervix, partly filling 
the vagina. This may be left for twenty-four hours, and replaced 
by a larger packing each day until the uterus becomes sufficiently 
dilated to admit the finger for palpation. These packings should 
be introduced at the patient's house or at a hospital, and the parts 
thoroughly disinfected before each packing. The packing should be 
examined each time for any abnormal secretion that may be found 
upon the uterine end. Unless the most perfect antiseptic precau- 
tions are assured, the packings should not be repeated many times, 



40 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

for the raucous membrane becomes denuded of its epithelium and 
exceedingly susceptible to septic inflammation. 

Rapid Dilatation of the Uterus for diagnostic purposes is usually- 
made under anesthesia, for which either the Sims' or the dorsal 
method of exposing the cervix may be employed. The cervix is 
drawn forward and steadied by a strong hook or vulsellum forceps. 
Conical dilators of constantly increasing sizes may then be forced 
into the uterus until a large curette or a finger can be used to explore 
the cavity. It usually requires an hour or so to dilate wide enough 
for the introduction of the index finger. In America the bladed 
dilators are usually preferred. It is preferable to use two or three 
sizes of these, first introducing a Nott or Ellinger dilator closed, 
and expanding the blades until the canal is large enough to admit 
a larger instrument, such as Goodell's, which in turn is expanded. 
The dilators should be turned from time to time so as to stretch 
the cervix antero-posteriorly, as well as laterally, and thus secure 
a greater and more general relaxation The blades of Ellinger's 
and Goodell's instruments remain parallel during expansion. 

It is sometimes almost impossible to dilate the nulliparous cervix 
at a single sitting wide enough to admit the finger to the fundus with- 
out lacerating the cervix. Hence in some cases only a moderate 
dilatation is attempted, and this is followed up by the method of tam- 
ponment already described. After abortions, or when the uterus 
is enlarged by growths or relaxed by inflammatory action, wide 
dilatation is often quite easily and rapidly accomplished. 

In other cases in which it is considered necessary to introduce 
the finger, an incision is made in front of the cervix, the bladder 
pushed up from its cervical attachment, and the anterior wall of 
the cervix is split as high as necessary. The incisions are sewed up 
immediately after the examination. This obviates the bruising of 
the cervix, yet the internal os and lower uterine segment may be 
so small that even this method fails to help us much. It is indeed 
seldom made use of for diagnostic purposes. 

Gradual Dilatation by means of sponge tents, tupelo tents, 1am- 
inaria tents, cornstalk tents, etc. was a once popular method that has 
now fallen into disuse, except in isolated cases in which the other 
means cannot conveniently be employed. 

Sponge tents expand quite rapidly, but they abrade the mucous 
membrane and sink into the cervical folds, so that portions of 
them are apt to be left after removal. This, together with the 



EXAMINATION OF THE FEMALE PELVIC ORGANS. 41 



fact that two or three must be successively used to obtain suffi- 
cient dilatation, exposes the patient to great danger from sepsis. 
The mortality attending their use is great ; the danger increases 
with each tent used. A 1 : 2000 bichloride vaginal douche should 
always precede their introduction and follow their withdrawal. 
They are best introduced in the lateral position by the aid of a 
Sims speculum, and should each be left in situ four or five hours. 
Tupelo tents are firmer and expand more slowly and efficiently. 
They slip out easily, and must be kept in place by a vaginal tampon. 
The same accidents are liable to happen as in using sponge tents, 
and the same precautions must be taken. 



Fig. 17. 



hBW 




TrL 



Palpation of the Interior of the Bladder. BGr, a a a, base of bladder : b b, mouths of ureters ■ TrL, 
interureteric ligament; hB W, posterior wall of bladder. 

Sea-tangle or laminaria tents often expand unequally, with a con- 
stricted zone corresponding to the internal os, which renders their 
removal difficult. 

Dilatation of the Urethra for digital examination and exploration 
of the bladder has been made jise of frequently. The danger of 
incontinence of urine has, however, deterred many from attempting 
it, and unless an hour or more is taken for the procedure this acci- 
dent is very liable to follow. Urethral sounds or dilators of graded 
sizes should be slowly and successively introduced until the little 
finger can enter the bladder. 



42 AN AMERICAN TEXT-BOOK OF GYNECOLOGY 

The anterior uterine wall, ureteral mouths, and inner surface of 
the bladder can be explored. In conjunction with one hand over 
the abdomen an accurate bimanual examination of the anterior half 
of the pelvic cavity can be made. In view of methods of bladder 
examination described in the chapter on Urethra, Bladder, and 
Ureters, this practice is altogether unjustifiable. 

Fig. 18. 



Exploratory Curette. 

The Dull Curette is used in scraping out retained secundines 
after abortion, or portions of intra-uterine malignant or adenoma- 
tous growths for macroscopical and microscopical examination. The 
sharp curette is, however, a much safer and more efficient instrument 
for this purpose. It can be used after moderate dilatation of the 
cervical canal. The small exploratory curette may be used for the 
same purpose, with the added advantage during its use of not being 
forced to dilate the cervical canal. 

The Exploratory Needle or Syringe is a valuable aid in the 
diagnosis of pelvic abscesses or cystic tumors, when such, aid is 
needed, which is of rare occurrence. It consists of a hollow needle 
or small trocar that can be attached to a syringe. After an anti- 
septic vaginal douche the patient is put upon her back, and the 
sterilized needle pushed into the tumor at a point in the disin- 
fected vagina where no pulsating vessel can be felt. If the needle 
be a fine one, there will be little danger even if the bladder, rectum, 
or a small blood-vessel be punctured, except from infection of 
the cyst contents, if it be not already septic. A few drops of fluid 
are drawn for inspection. 

An Aspirator may be used in the same way as the exploratory 
needle, the chief difference being that more fluid, or even all of it, 
can be withdrawn. 



THE TECHNIQUE OF GYNECOLOGICAL OPERATIONS. 



Technique, in gynecology, is a word used to designate certain 
features in the details of an operation essential to its proper per- 
formance, and is the most powerful factor in ensuring its success. 
It has nothing to do with the diagnosis, the prognosis, or the 
determination to operate, but, having determined to operate, it 
concerns itself with every act, from the preliminary preparations 
to the completion of the operation. To assert, therefore, that the 
technique in a given operation is faultless, is to credit the surgeon 
with the highest scientific knowledge of his specialty, and the 
skill to properly utilize it for the benefit of his patient. 

Imperfect technique implies errors of omission or commission 
on the part of the operator which may prove detrimental to the 
recovery of the patient or even cost her her life. With a perfected 
technique, therefore, the surgeon is acquitted of personal responsi- 
bility as to the result, providing his judgment in electing to ope- 
rate has been good ; while if his technique is bad he always stands 
arraigned before the bar of criticism, and is directly responsible for 
the bad results of his work. 

The technique of an operation is thus made to include all those 
features which scientific investigation and consensus of opinion have 
shown to be conducive to success in the greatest number of cases. 

It has nothing to do with dexterity, rapidity, or any other 
personal element in the operation, but is the basis or pervading 
principle of the work. 

As it is the animating principle of successful operations, it 
is in the highest degree important to devote a separate chapter 
in a practical work on gynecology to the consideration of such 
technical details as are more or less common to operations in gen- 
eral, or to certain classes of operations. The variations in the 
technique of each individual operation must be left to the system- 
atic description of the operation in its appropriate chapter. 



44 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

The evolution of gynecology to its present high position as a 
specialty is due undoubtedly to the improvements in the operative 
technique. 

In the earliest times there was no technique : the operator treated 
each case according to his own inclinations. Gradually, as the re- 
sults of observations accumulated, individual operations crystallized 
in definite forms, and the technique of the operation was thus estab- 
lished. Further experience demonstrated the existence of certain 
underlying principles common to groups of operations, and culmin- 
ated in one grand principle, antiseptic technique. This principle 
has proved the quickening element in the whole field of modern 
gynecology, giving life to old operations, calling new operations into 
existence, and yearly saving thousands of lives. 

Sepsis, Asepsis, Antisepsis. 

A proper realization of the significance of these three terms to 
practical gynecology constitutes the very essence of successful work. 
The cause of death after operation, in the vast majority of cases, is 
sepsis or germ-infection. 

There is no longer any discussion among intelligent men as to 
whether certain forms of germs are dangerous and destructive to life, 
but the question is : Under what circumstances do these germs in- 
vade the tissues, and what are the best methods for excluding them ? 

Sepsis is the condition of infection resulting from the presence 
of one or more pyogenic organisms, such as the staphylococcus pyog- 
enes aureus, staphylococcus pyogenes albus, streptococcus pyog- 
enes, bacillus coli communis, gonococcus of Neisser, and also other 
rarer pyogenic forms. 

Any of these organisms may be found pre-existing in the genital 
tract ; the first and third are found oftenest in tubal abscesses. The 
second is found chiefly in stitch-hole abscesses. The colon bacillus 
exists in the intestinal tract, and may occasion a general peritonitis 
after an operation if the intestine is seriously wounded. Strepto- 
cocci are for the most part found in the purulent inflammatory con- 
ditions following abortion or puerperal fever. 

These are peculiarly virulent, and a little of the pus remaining 
in the pelvis is often sufficient to cause the death of the patient by 
a rapidly developing peritonitis. 

The most harmless pus is that containing gonococci, as it is prob- 
able thai these organisms die early. Pyogenic organisms are intro- 



THE TECHNIQUE OF GYNECOLOGICAL OPERATIONS. 45 

duced into wounds by the fingers of the operator, or on instruments, 
sponges, ligatures, or other objects not properly sterilized. 

Asepsis means freedom from pyogenic organisms, and is the ideal 
condition for the hands of operator and assistants and for the 
instruments, sponges, ligatures, etc. 

The surfaces of all objects exposed to the air are covered with 
bacteria ; the hands not only become contaminated, but pyogenic 
bacteria may multiply beneath the finger-nails, and the most viru- 
lent germs may be transported from case to case. Relative to the 
operation, therefore, all objects not specially prepared and cleansed 
are germ-infected or septic. 

Antisepsis is the application of any efficient means for getting 
rid of germs. It may be mechanical, as by scrubbing or washing ; 
chemical, as by the use of carbolic acid or bichloride of mercury ; or 
thermic, by boiling water or steam. 

Mechanical antiseptic measures are of the utmost value in remov- 
ing from the hands those germs which can be easily dislodged, though 
by this means alone the hands cannot be rendered perfectly sterile. 

Chemical sterilization by drugs is becoming of less and less im- 
portance. A prolonged immersion of the hands in bichloride-of- 
mercury solutions as strong as 1 : 500 does not render them so sterile 
as the permanganate of potash and oxalic acid, yet it answers the 
purpose and is used by a large number of operators. Carbolic 
acid cannot be used for this purpose in efficient strength without 
injury. 

Sterilization by Steam and Boiling Water has with complete satis- 
faction replaced all other measures in the sterilization of instruments, 
dressings, and ligatures. 

An exposure to steam heat at 100° C. or 212° F. for a half hour 
will destroy all germs in cotton, gauze, bandages, or other dressings. 
If repeated on two successive days, the spores are destroyed, and 
objects so treated will remain sterile until exposed to contamination. 
A boiling 1 per cent, solution of the carbonate of soda will sterilize 
instruments in five minutes without tarnishing them or dulling the 
edge. 

Technique in General. 

1, Operating-room; 2, Surgeon, assistants, nurses; 3, Instru- 
ments ; 4, Ligature and suture materials ; 5, Dressings and sponges ; 
6, Towels, sheets, blankets, operating suits; 7, Drainage. 



AN AMERICAN TEXT- BO OK OF GYNECOLOGY. 



Operating-room. 

The requisites for a gynecological operating-room are — a floor on 
which water can be used freely, a good illumination, and an abun- 
dant supply of hot and cold water. A closely -joined wooden floor, 
if well paraffined, is satisfactory. The best floor, however, is made 
of encaustic tile, closely laid, as it does not absorb moisture. 

The light in the operating-room should come from windows with 
a northern exposure and from a large skylight. Too strong light 
or direct rays from the sun embarrass the operator and spectators, 
blinding the eyes, and throwing the parts below the surface into 
deep shadow. 

Fig. 19. 




sterilizer, Demijohn, Basin-1 



inges, Sutures, etc. 



There should be an abundant supply of hot and cold water. The 
hot or cold water circulating in the pipes will do for the purpose of 
preliminary cleansing and for washing the hands, but should in no 
way conic in contact with the field of operation unless previously 
sterilized by boiling. 

In the operating-room there must be several wash-basins sup- 
plied with hot mid cold water; also a large sink with an abundant 



THE TECHNIQUE OF GYNECOLOGICAL OPERATIONS. 47 

water-supply, and drip-stones near by for dishes. There must also 
be an apparatus for steam disinfection, and vessels for the boiling 
soda solution and for boiling water. 

In another part of the room the ligatures, gauze drains, sponges, 
and the sterilized gauze and cotton are stored in glass jars. 

The instrument-case is provided with glass shelves, as they are 
easily kept clean and expose all the instruments to view. The 
instruments are kept properly classified in groups — scissors, knives, 
forceps, etc. 

Adjoining the operating-room is a small room for the adminis- 
tration of anesthesia. The patient is brought here from the ward 
and anesthetized without witnessing any of the preparations which 
have been made for her reception in the operating-room. 

After each operation the floor is cleansed by mopping with water. 
Occasionally the walls should be gone over with a damp cloth. 
A good enamel paint will resist the discoloring effects of the 
moist atmosphere of the room. 

Some operating-rooms are conveniently arranged with subsid- 
iary rooms in which all the preparations for an operation are made, 
leaving the room for the operation perfectly clear for operator, 
assistants, and spectators. This is a more convenient arrange- 
ment when the operations are frequently performed in the pres- 
ence of large classes. These same principles may be carried out 
in a private residence as efficiently, if not so elaborately, as in the 
hospital. 

The accompanying cut of one of the operating-rooms of the 
Gynecean Hospital, Philadelphia, prepared for an operation, shows 
at a glance how easily and simply the indications can be met. It 
will be seen that there are but few articles in the room which can- 
not be obtained or substituted in any well-regulated private resi- 
dence. A plain kitchen table may be made to answer the purpose 
of the operating-table. If it is desirable to use the Trendelenberg 
position, a Krug frame can readily be taken to the house in the 
physician's carriage. Instruments may be boiled in any conve- 
niently-sized tin basin. Five- or ten-gallon demijohns of dis- 
tilled water may be usually obtained, but if not, boiled water will 
answer all purposes. If it be muddy, it should of course be filtered 
before boiling. 



48 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

The Operator and his Direct Assistants. 

The responsibility of the operator and his assistants does not 
begin, as it is commonly believed, in the preparation immedi- 
ately before the operation. It is a duty, always devolving upon all 
persons who come in direct contact with wounds of any sort, to avoid 
at all times unnecessary contact with septic matter. Unhealthy or 
suppurating wounds should never be touched with the fingers when 
it is possible to avoid it ; dressings of such wounds should be re- 
moved and replaced by forceps. 

The gynecologist has no right to conduct post-mortem examina- 
tions or handle pathological specimens. When contact with possibly 
infected objects is necessary, the lodgement of infection in the skin 
and under the nails should be prevented as far as possible by coat- 
ing the surface of the fingers and hand with vaseline, and making 
the contact as brief as possible ; and this should be followed imme- 
diately by a thorough scrubbing of the hands. 

The surgeon and his assistants, like obstetricians, should avoid 
the habit of wearing gloves which cannot be washed. Contamina- 
tion is often conveyed by examining a septic case, hurriedly wash- 
ing the hands, and drawing on gloves which become thus contam- 
inated, and which in turn reinfect the hands each time they are 
worn. 

Both surgeons and assistants should bathe frequently and wear 
clean apparel. It adds to the comfort, as well as harmonizes with 
the sense of cleanliness, if the surgeon can step from his bath into' 
his operating suit. Operating suits for surgeon and assistants should 
be made of stout butcher's linen. The jacket should be open in 
the back ; the pantaloons may be separate or attached to the jacket. 
Tapes should be used in place of buckles for the pantaloons. The 
sleeves should be short, reaching to within two or three inches of 
the elbow. Before putting on the suit the outer clothing should be 
removed down to the under-clothes. It is in better keeping with 
the appearance of the rest of the costume to wear also white linen 
caps and white canvas shoes with rubber soles. The nurses must 
wear wash dresses with fresh white front and short sleeves. 

For operations in private houses aprons of stout butcher's linen 
sufficiently long to cover the clothing from the neck to the ankles 
will give the proper amount of protection. 

Cleansing the Hands and Forearms. — The first duty after enter- 



THE TECHNIQUE OF GYNECOLOGICAL OPERATIONS. 49 

ing the operating-room is to cleanse the hands and forearms thor- 
oughly at the basin with a stiff scrubbing-brush, soap, and warm 
water, frequently changing the water. At least ten minutes must 
be spent in scrubbing the hands and forearms, paying especial atten- 
tion to the finger-nails. 

After washing the hands and forearms they are immersed in a 
hot saturated solution of permanganate of potash until they are 
stained a deep mahogany-red, when they are decolorized in a hot 
saturated solution of oxalic acid. The hands are then washed off 
in milk of lime or in plain water to remove the oxalic acid. The 
nurses who handle sponges, gauze, prepare ligatures, etc. must also 
wash and sterilize their hands in the same way. 

A common and excellent substitute for this method of steriliza- 
tion is to bathe the hands and arms in alcohol after scrubbing them 
with the nail-brush and soap. They are then soaked in a strong 
bichloride-of-mercury solution (1 : 500) for five minutes, and the 
bichloride is finally washed off with sterilized water. 

After such preliminary sterilization the operator must avoid con- 
tact with non-sterilized objects, such as lids of jars and vessels, door- 
handles, tables, any part of his own person, such as the hair or 
eye-glasses, or the patient ; above all must such inconsistencies as 
shaking hands with visitors, putting the hands in the pockets while 
waiting, etc. be avoided. 

When it is necessary to come in contact with the patient, as in 
placing her on the pad or in removing the bandages, the hands 
must again be cleansed by washing for two minutes. During the 
course of the operation the operator and assistant should frequently 
rinse off their hands in a basin of warm sterilized water which is 
kept standing in a convenient position for that purpose. 

Instkuments. 

After each operation the instruments are immersed in hot 
water and scrubbed with soap and a scrubbing-brush. They are 
then rinsed in hot water and placed upon a clean dry towel, and 
rapidly dried, the heat from the water assisting in this process. 
After drying the instruments they are classified in separate groups 
on the shelves in the instrument-case. Before the next operation 
they are collected in a linen bag and placed in the sterilizer. If 
the operation has been a septic one, they are sterilized before put- 
ting them away, and again just before the succeeding operation. 



50 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



The sterilization of instruments is simply and efficiently effected 
by boiling them in a solution of carbonate of soda, of 1 per cent, 
strength, for ten minutes. The bag is then picked up by the draw- 
string, which has been left hanging out over the edge of the vessel, 
and carried to the instrument dishes, which have been arranged on 
a table convenient to the operator or assistant who is to handle them, 
into one of which it is emptied. If a wire or perforated tray be 
used upon which they are boiled, the tray may be lifted from the 




I'laoiriK Instruments in Arnold's Sterilizer, in Linen Bag. 

sterilizer, placed on the instrument-table, and the instruments used 
directly from it. Cold sterile water is poured over the instruments, 
and when cooled they are appropriately classified. The instruments 
should be kept bright and free from tarnish by the occasional use 
of a fine soap, such as sapolio, used for polishing metallic surfaces. 

Ligatures and Suture Materials. 
The ligature and suture materials used in gynecology are silk, 
catgut, silkworm-gut, and silver wire. 



THE TECHNIQUE OF GYNECOLOGICAL OPERATIONS. 51 

Tendon sutures, while excellent, are too expensive to come into 
general use. The silk should be of the twisted Chinese variety of 
three grades — fine silk, used as carrier threaded in the needle, by 
means of which the sutures are pulled through the tissues ; inter- 
mediate silk, for all ordinary purposes of suture and ligature, even 
for ligating the ovarian and uterine arteries and approximating the 
edges of the stump in hysterectomy for myoma ; and heavy silk, 
for ligation in vaginal hysterectomy. 

Fig. 21. 




Silk in Tubes for Sterilization. 



The silk is sterilized by placing it in stout glass tubes made for 
this purpose, or in pieces of stout glass tubing an inch in diameter, 
plugged at both ends with cotton. The silk should be cut in 
convenient lengths and rolled loosely on glass reels which fit the 
inside of the tube. The tube is then placed in the sterilizer, 
steamed for an hour, taken out, and the process repeated a half 
hour on two succeeding days. The cotton is left in place until the 
sutures are used. The ligatures are sterilized by this fractional 
method of sterilization with absolute certainty, as this is the 
method employed in the bacteriological laboratory for sterilizing 
culture media. The steam penetrates the cotton and circulates with 
perfect freedom in the tube. 

Where steam is constantly circulating through the establishment, 
it may conveniently be utilized for sterilization by tapping the pipe 
into a copper cylinder. A coil of pipe filling the inside of the cylin- 



52 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

der, also connected with the steam system, serves to keep up a high 
temperature and to dry out the dressings when the free steam is 
turned off. 

Of the steam sterilizers, that of Arnold is the best for transpor- 
tation to private houses and for clinics not fitted with special con- 
veniences. 

Silkworm-gut is sterilized in the same manner as the silk. It 
should be assorted into light and heavy sizes. 

Catgut. — Catgut is ruined by water or steam, and requires, there- 
fore, a different mode of sterilization. The following method is that 
of Kronig, modified in some particulars : 

1. Cut the catgut into the desired lengths, and roll twelve strands 
so that they may be slipped into a large test-tube. 

2. Bring the catgut gradually up to a temperature of 80° C, 
and hold it at this point one hour. 

3. Place the catgut in cumol, which must not be above a tem- 
perature of 100° C, raise it to 165° C, and hold it at this point for 
one hour. 

4. Pour off the cumol, and either allow the heat of the sand- 
bath to dry the catgut or transfer it to a hot-air oven at a tempera- 
ture of 100° C. for two hours. 

5. Transfer the catgut with sterile forceps to test-tubes previously 
sterilized, as in the laboratory. 

If convenient, it is better to use the hot-air oven for the drying 
process, but this is not absolutely essential, as a sand-bath can be 
improvised to serve this purpose. 

A beaker-glass of at least a half-litre capacity is imbedded 
three-fourths of its height in a tin or agate-ware vessel of sufficient 
capacity to permit three-fourths of an inch of sand to be packed 
about the sides and beneath the glass. 

In drying or boiling the catgut should not come in contact with 
the bottom or sides of the vessel, but should be suspended on slender 
wire supports or placed upon cotton loosely packed in the bottom. 

During the drying process the beaker-glass is covered with a 
sheet of pasteboard, through which a centigrade thermometer is 
thrust, so that the mercury bulb may be suspended about midway 
in the vessel. In this way the temperature can be regulated per- 
fectly. 

A Bunsen burner is placed under the sand-bath, and the tem- 
perature in the beaker-glass is slowly brought up to 80° C, where 



THE TECHNIQUE OF GYNECOLOGICAL OPERATIONS. 53 

it is held for one hour, to dry the catgut. A higher temperature 
than 100° C. before the catgut is thoroughly dry renders it brittle ; 
this step in the method must be carried out most carefully. 

When the drying process is completed the cumol is poured into 
the beaker-glass and brought up to a temperature of 165° C, a 
little short of the boiling-point, with two Bunsen burners. A 
copper wire netting should be placed over the beaker-glass to pre- 
vent the ignition of the cumol. This temperature is more than 
sufficient to kill all micro-organisms, and it is not necessary to allow 
the cumol to boil, which causes unnecessary evaporation. The 
catgut is left for one hour at this temperature, Avhen the cumol is 
poured off for subsequent use. 

Cumol, which is of a clear limpid or slightly yellowish appear- 
ance when procured from the chemist, is changed to a brownish 
color by boiling. 

The catgut is allowed to remain in the sand-bath until the excess 
of cumol is driven off and it appears entirely free from any oily 
matter. A period of one to two hours is usually sufficient to dry it 
thoroughly. 

From the sand-bath or hot-air oven it is transferred with sterile 
forceps to sterile test-tubes, such as are used for culture media, in 
which it is preserved from contamination until ready for use. 
Small quantities should be placed in each tube to obviate the neces- 
sity of opening them too frequently. The tubes should be plugged 
with sterilized cotton. 

In conclusion, it is well to bear in mind that while cumol is not 
explosive it is very inflammable, and great care should be observed 
in lifting the wire screen from the beaker-glass to prevent drops of 
the cumol from falling in the flame or on the heated piece of metal 
on which the sand-bath rests, as it will take fire, flare up, and ignite 
the fluid in the beaker-glass. Such an accident has occurred three 
times in our experience. 

Another equally efficient method of preparing catgut is as fol- 
lows : 

(1) Soak the raw catgut for one week in oil of juniper, (2) forty- 
eight hours in ether; (3) forty-eight hours in plain alcohol, and 
finally boil for two hours in an alcohol bath. Keep in alcohol until 
wanted. 

Each portion of catgut taken from the stock -jar for an operation 
is to be boiled for twenty minutes in alcohol before being used. 



54 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

Only a small portion of gut should be prepared at one time, as too 
frequent boiling renders it brittle and liable to break. 

Dressings and Sponges. 

Sponges are prepared by pounding them in a wooden bowl to 
loosen the grit, and then washing them in warm water until the 
water remains clear. It may be necessary to change the water eight 
or ten times. From the water they are transferred to dilute hydro- 
chloric acid (.5ij to Oj) and allowed to stand for twenty-four hours. 
This part of the process is necessary to remove all chalky par- 
ticles. From the hydrochloric acid they are passed quickly through 
permanganate-of-potash solution (5 per cent.), which stains them a 
dark purple ; the sponges are then decolorized by immersing in a 
saturated solution of oxalic acid. Before transferring the sponges 
to the oxalic-acid solution the hands should be disinfected after the 
same method as for operation, as the permanganate of potash and 
oxalic acid are the essential factors in the process of sterilization, 
and the sponges must not be contaminated from this stage on. From 
the oxalic-acid solution, where they have remained only a sufficient 
time to effect decolorization, they are transferred to sterilized lime- 
water, which neutralizes the acid, and then into bichloride-of-mer- 
cury solution (1 : 1000) for twelve hours, after which they are rinsed 
twice in sterilized water and preserved in carbolic-acid solution (3 
per cent.) until they are desired for use. 

After being washed free from the hydrochloric acid another good 
method for cleansing is to immerse the sponges in a saturated solu- 
tion of washing soda for forty-eight hours, from which they are 
taken, thoroughly washed free from the soda, and immersed in a 
bichloride-of-mercury solution (1 : 1000) for twelve hours, after 
which they are placed in alcohol, where they are kept until used. 
After being soiled at one operation they may be prepared for further 
use by the same method : prior to placing them in the mercurial 
solution, however, they are immersed in a strong sulphurous-acid 
solution for twelve hours for the purpose of decolorization. 

When gauze is used for sponges it should be thoroughly sterilized 
in steam by the method used for sterilizing the dressings. 

Gynecological dressings consist of sterilized absorbent cotton and 
iodoformized gauze and abdominal and T-bandages. 

Absorbent cotton is unrolled from the bales in which it is bought 
and cut into pieces of various sizes or made into loose balls. The 



THE TECHNIQUE OF GYNECOLOGICAL OPERATIONS. 55 

large pieces are laid in a towel, which is pinned together so as to 
completely protect the cotton. They are then thoroughly sterilized 
for several hours in the steam sterilizer. The balls are sterilized for 
several hours in a glass jar, which is left open during the process; 
at the end of this time the free steam is cut off and that circulating 
through the coil allowed to dry them out thoroughly. 

Gauze. — Gauze is bought in rolls of one hundred yards each, 
at a little over three cents a yard. It is cut into strips of several 
yards' length, and then sterilized in the same manner as the cotton 
and other dressings. Both gauze and cotton are used preferably by 
many operators after they have been impregnated with bichloride 
of mercury. Such material should never be used inside the perito- 
neal cavity. It may be bought already prepared in the shops, but 
should be resterilized by steam for several hours before using. 

Iodoformized gauze is prepared by impregnating rolls of sterilized 
gauze with an emulsion of iodoform in soapsuds and water. This 
should also be subsequently sterilized for several hours in steam. 

Towels; Sheets; Blankets; Operating Suits. 

All towels, sheets, blankets, bed-clothes, or any similar articles 
used about the patient or brought into the operating-room, as well as 
the doctors' and nurses' aprons and operating suits, after being 
securely wrapped in towels should be subject to several hours' steril- 
ization in the steam sterilizer. All glass-ware, iron, wooden, or 
rubber utensils used in or about the operation must be sterilized by 
being scrubbed with soap and water, douched with boiling water, 
and finally mopped with a strong bichloride-of-mercury solution 
(1:200). 

Drainage. 
Roll Gauze and Mikulicz Brains are rarely useful. These drains 
are difficult to remove, and cause the patient much distress, as they 
cling closely to the skin and the underlying tissues. They not in- 
frequently defeat the object for which they are used by damming 
back and allowing an accumulation of the fluids to be drained. 
The roll-gauze drain is made by forming a piece of gauze a yard 
long into a loose roll about three-quarters to one inch in diameter. 
Pieces of the length desired can be cut off. The Mikulicz drain is 
made of a gauze bag one or two inches in diameter and about eight 
inches long, with a string tied to its bottom, the end of which string 



56 AN AMERICAN TEXT- BOOK OF GYNECOLOGY. 

protrudes from the mouth of the bag. This bag is loosely filled with 
three or four loug strips of gauze, about two and a half inches 
wide, which project from the top of the bag. A good substitute for 
this drain is to fill loosely a soft-rubber tube (an ordinary rubber 
condom with the closed end cut off), open at both ends, with a strip 
of roll-gauze drain. 

All these drains are carried to the point which it is desirable to 
drain, and the opposite end is left protruding from the lower end of 
the wound. The drainage is effected by capillary attraction, which 
carries the discharge to the surface, where there must be an abun- 
dance of sterilized cotton to take it up. It is necessary to change 
the dressings frequently the first day or two. The drains are re- 
moved in several days, and a small rubber tube substituted tempo- 
rarily until the drainage tract has contracted. It may be preferable 
to pass a single strip of gauze to the bottom of the drainage tract 
instead. This is ordinarily removed permanently within another 
day. Circumstances may, however, demand its retention several 
days longer. At times it becomes necessary to pack the pelvis 
or a portion of it with gauze for the purpose of checking oozing, 
which cannot be controlled otherwise on account of the difficulties 
of so doing or because it is dangerous to prolong the operation. 
This is best accomplished with long strips of gauze several inches 
wide and several yards long. But one strip should be used if pos- 
sible. Great care must be observed to pack the gauze in concen- 
tric layers, else it will be found exceedingly difficult to remove. 
This pack holds the bleeding in check by direct pressure, and at 
the same time, to an extent, serves the purpose of a capillary drain. 
The end is left hanging out of the lower opening of the abdominal 
incision, and requires the same care as do all gauze drains. It 
should be removed within two days, and better still at the end of 
one day, by pulling on the protruding end. 

In all gauze drains it will be found necessary to free with a probe 
that portion of the gauze passing through the abdominal wall and 
adherent to its tissues. Not infrequently after withdrawing the 
gauze a knuckle of the intestine or omentum will be found to have 
been drawn into the incision. This must be carefully replaced by 
means of a sterilized probe, the parts cleansed, and the gaping 
incision brought together by means of a piece of sterilized gauze 
and a strip of adhesive plaster. 

Glass drainage is used more frequently than gauze, but in care- 



THE TECHNIQUE OF GYNECOLOGICAL OPERATIONS. 57 

less hands it is exceedingly dangerous, and should be avoided, as 
should ail drainage, except when absolutely necessary. Drainage 
of any kind is rapidly becoming a thing of the past in abdominal 
surgery. 

The drainage-tube should be about six inches in length and of 
a calibre just sufficient to admit the nozzle of the syringe used in 
cleansing it. It should be sterilized by being boiled with the instru- 
ments in soda solution. The object of the tube is to keep the 
cavity to be drained perfectly dry. To accomplish this it is neces- 
sary, at times, directly after the operation, to cleanse the tube every 
fifteen minutes. In the course of a few hours the intervals of cleans- 



Fig. 22. 

■ m^. 





Hard-rubber Syringe, for cleansing drainage-tube. 

ing are lengthened, until it is not repeated oftener than three or 
four times a day. The tube is removed as soon as the discharge 
assumes the straw color of the normal peritoneal fluid and the 
amount is diminished to a few drachms at each cleansing. The 
tube is kept dry, while in situ, by passing a long-nozzled syringe to 
its bottom and removing the accumulated fluids by suction. Before 
and after each cleansing the mouth of the tube and the rubber-dam 
through which it projects must be washed carefully with a piece of 
cotton dipped in bichlorick-of-mercury solution ; the syringe should 
be disinfected both inside and out with bichloride solution and boil- 
ing water. The hands of the person cleansing the tube must be 
carefully disinfected before each dressing, no matter how often re- 
peated. In no other way can the safety of the patient be ensured. 
Fresh sterilized cotton is placed over the mouth of the tube each 
time it is disturbed, and is held in place by a square piece of 
rubber-dam, through the centre of which the free end of the 'tube 
protrudes. 



58 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

The Technique of Vaginal Operations (not Opening the 
Peritoneal Cavity). 

Preceding a plastic operation upon the vagina or external geni- 
tals the bowels should be thoroughly evacuated by two or three free 
purgations, started with a laxative, such as a pill composed of aloes 
gr. j, belladonna gr. -}, and strychnia gr. %\, taken thirty-six hours 
before the time of operation, followed, if necessary, by citrate of 
magnesia. A Seidlitz powder or several large (3j) doses of magne- 
sium salts twenty-four hours before operation, followed by a rectal 
enema the next morning, is also efficient. A vaginal douche of 
bichloride of mercury (1 : 3000) should be administered daily for 
some days prior to operation where possible. The day before the 
operation the diet should be light, with no breakfast the following 
morning. 




Robb's Modification of Kelly's Leg-holder. 

In perineal, vaginal, and rectal operations the patient is brought 
down to the edge of the table, with the thighs well flexed on the 
abdomen and held in this, position by a leg-holder. The simplest 
form of leg-holder is that devised by Robb. One of the ends is placed 
around the leg just above the knee, and is then hooked into one of 
the rings on the shoulder-strap. The other end is drawn under the 
arm, around the back of the neck, down over the opposite shoulder, 
and hooked about the opposite leg above the knee. Like every- 
thing else used about an operation, it should be sterilized. This is 
readily done by means of the steam sterilizer. 

The leg-holder may be dispensed with, and an assistant's hands 
substituted. 



THE TECHNIQUE OF GYNECOLOGICAL OPERATIONS. 59 

The perineal pad is next inflated and placed under the but- 
tocks, with the apron dropping into a bucket at the foot of the table. 

In vaginal operations the preparatory cleansing is conducted as 
follows: The external genitals are thoroughly soaped, and this 
worked up into suds with warm water ; the hair is next shaved 
off the vulva, although this procedure is by no means absolutely 
necessary, provided the operator takes sufficient care to render the 

Fig. 25. 




Assistant Supporting Legs. 



hairs aseptic. The vagina is thoroughly cleansed with soap and 
warm water. A 10 per cent, solution of creoline makes an excel- 
lent detergent if applied vigorously by means of a ball of absorbent 
cotton in the grasp of a pair of forceps, so as repeatedly to stretch 
out and cleanse every little fold and rugosity. The parts around the 
field of operation are protected in the following manner : A dia- 



60 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

phragm composed of three or four thicknesses of gauze is laid over 
the vulva, inner surfaces of the thighs, and buttocks, reaching well 
down below the border of the table. Through a slit in the centre 
of this the operation is performed. The legs of the patient are 
covered with loose sterilized stockings reaching above the knees, 
where they are tied with draw-strings. 

The irrigator is of great service in perineal work. By its use 
sponges are dispensed with, and the blood which is at once diluted 
fails to clot, and does not cling to the fingers. 

The best form of irrigator is a large glass jar placed on a shelf 
three feet above the head of the operator. An opening near the 
bottom provides for the escape of the water, which is conducted 
through a rubber tube and ends in a glass nozzle with an interven- 
ing stopcock. 

The Technique of Abdominal Operations. 

The technique of abdominal operations begins with the prepa- 
ratory treatment of the patient immediately before operation, and 
includes all the details in the preparations for and the carrying out 
of the operation. Certain features are common to all abdominal 
operations. Of these but two will be described : the opening 
and closing of the abdomen. 

Preparatory Treatment. — It is necessary to begin in some cases 
weeks beforehand if the patient be in an enfeebled condition and 
there is any prospect of building her up for the operation. The 
most important elements of the treatment are rest in bed, digesti- 
ble food at frequent intervals, stimulants and tonics if well borne, 
regulation of the bowels, and quickening the activity of the skin by 
baths, massage, and electricity. Strychnia in doses of ^\ of a grain 
three times daily is indicated in all such patients. In other cases, 
where the general condition is good, a delay of but one or two days 
is necessary in which to bathe the patient and thoroughly evacuate 
the bowels. Almost all chronic cases, not excluding pelvic ab- 
scesses, will be befineted by preparatory treatment. 

Such cases as extra-uterine pregnancy with internal hemorrhage, 
rupture or strangulation of a cyst, acute septic conditions, or rupture 
of an abscess call for immediate operation. Here all the advantages 
of rest and preparation are subordinate to the paramount danger 
which threatens to destroy life. Occasionally it will be necessary 
to give the patient an anesthetic, and without preliminary prepara- 



THE TECHNIQUE OF GYNECOLOGICAL OPERATIONS. 61 

tion lift her on to the ovariotomy pad upon the table, where the 
vagina is douched out with a strong boric-acid solution, or a 10 
per cent, creoline solution, or a 1 : 1000 solution of bichloride of 
mercury. The mons veneris is shaved well down to the labia, the 
abdominal walls cleansed, and celiotomy performed at once. 




Ordinarily the patient has a warm bath and a vaginal douche of 
bichloride of mercury (1 : 2000) daily for several days. The morn- 
ing before her operation purgatives are administered : magnesia 
salts in some form in half-ounce doses are taken hourly until the 
the bowels begin to move, which will generally be after the admin- 
istration of four or five doses. A full dinner is allowed, but only 
a light supper ; no breakfast is taken the next morning. In the 
morning an enema of soap and warm water is given, and the vagina 
is prepared by being washed thoroughly with soap and hot water, 
followed by alcohol and a bichloride-of-mercury solution (1 : 1000), 
and finally packed with sterilized gauze, after which the patient is 
put in a hot soap-bath, where she is well scrubbed with a flesh- 
brush, special attention being given to the abdomen and buttocks. 



62 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

On coming from the bath she is given a fresh sterilized night-gown 
and goes to her bed, which in the mean time has been made up with 
fresh sterilized bed-clothing. The abdomen is to be thoroughly 
prepared in the bed by first scrubbing with soap and hot water 
with the aid of a nail-brush, followed by alcohol and ether, and 
this by a strong bichloride-of-mercury solution (1:1000). The 
abdomen is covered, with a pad of sterilized gauze, to prevent con- 
tamination of the skin in transporting her to the operating-room. 
While the anesthetic is being administered a nurse whose hands 
have been thoroughly cleansed empties the bladder with a sterilized 
catheter, after which the vulva is mopped off with a bichloride-of- 
mercury solution. 

The patient is placed on the table with her hips resting on 
Kelly's ovariotomy pad, the apron of which hangs over the side of 
the table into a bucket. The assistant, after removing the sterilized 
gauze pad, now finally cleanses the abdomen by first scrubbing it 
with a ball of cotton and ether, and then with pure alcohol. 

Sterilized towels are used to protect the thighs and chest, and 
over the abdomen, chest, and thighs a large piece of sterilized gauze, 
three folds thick, is laid. This is split open for a short distance in 
the median lino, and through this opening the operation is conducted 
with a minimum danger of infection from the patient's skin. 

Opening the Abdomen. — The usual location for the incision is in 
the median line between the umbilicus and pubes, nearer the pubes. 

For making the incision a sharp scalpel, two pairs of rat-tooth for- 
ceps, and one or two short sharp-nosed artery forceps are necessary. 

The operator steadies the abdominal wall and holds the skin a 
little taut, between the thumb and middle finger of the left hand, 
while the right hand makes a sweeping incision vertically down- 
ward in the median line from two to eight inches long, according 
to the nature of the operation. In doubtful cases a shorter incis- 
ion should be made first, and afterward lengthened if necessary. 

After passing through skin and fat the sheath of one of the recti 
muscles appears. This white and fibrous layer may be cut a little 
obliquely, when the incision is almost sure to cross the linea alba, 
seen between the two red muscles. The incision is continued down 
between the muscles in the linea with the aid of an assistant, who 
catches the lissue of one side with his forceps, while the operator 
docs likewise on the opposite; side. Thus the tissues are lifted up and 
drawn apart, layer by layer. The superficial fat, which is of variable 



THE TECHNIQUE OF GYNECOLOGICAL OPERATIONS. 63 

thickness, appears next, and beneath this the thin, delicate perito- 
neum. The peritoneum must be caught very superficially in the for- 
ceps and gently incised, so as merely to nick it. The intestines drop 
back the moment the smallest opening in the peritoneum is made, and 
then the incision can boldly be enlarged upward and downward to 
both extremities of the incision. In enlarging the incision the ope- 
rator should always glance through the peritoneum which is lifted 

Fig. 27. 




up by forceps, to assure himself that he is not opening an abnor- 
mally high bladder. 

The bleeding from the walls of the incision, although stimulated 
by the massage given in scrubbing the skin just previous to the 
operation, is usually slight, and ceases spontaneously, as a rule. If 
too free, one or more vessels may be caught with artery forceps, 
which can be removed at a later stage of the operation, when the 
bleeding will have ceased. Occasionally a large spouting artery 
requires immediate ligation with the finest silk or catgut ligature. 
If the incision proves too small, it may quickly be enlarged by 
cutting upward with a pair of scissors rounded on the points, 
guided by a finger within the abdomen, which protects the viscera 
from injury. 

Closure of the Abdominal Ineision.— -The incision should be 



64 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

closed by two or three rows of sutures ; one continuous suture of 
fine catgut uniting the peritoneum, transfixing each side three or 
four times to the inch. Immediately overlying the peritoneum are 
the recti muscles, and over these, often a little retracted from the 
margins of the wound, are the cut edges of the strong fibrous fascia. 
These are approximated by a layer of interrupted, buried silver-wire 
sutures, about one or two to the inch, taking great care to bring 
together the edges of the fasciae of the two sides from top to bottom 
of the wound. This is the most important step in. the closure, as 
in this fascia lies the strength of the abdominal wall, and in its 
proper reunion lies the protection against a ventral hernia which 
may arise as a sequel to the operation. The interrupted sutures 
should be drawn sufficiently tight to hold the parts snugly together, 
but never tight enough to constrict the tissues. The ends are 
twisted together, and then turned downward to prevent any irrita- 
tion. The approximation of the skin may be secured either by an 
interrupted silkworm-gut or a continuous fine catgut suture, entered 
below the lower angle of the wound, passing from side to side sub- 
cutaneously, and reappearing above the upper angle. 

A simpler and more satisfactory method of closure is to place a 
series of interrupted silkworm-gut sutures about one-third of an 
inch apart, each including all the tissues of the abdominal wall 
(skin, peritoneum, and all intervening tissues). Before tying these 
sutures the edges of the divided deep fascia are brought together 
by means of a continuous catgut suture, the ends of which are cut 
short. The through-and-through silkworm-gut sutures are then 
securely tied. 

Dressing the Wound. — The skin is first carefully dried with 
sterile gauze or with a sterile sponge, and three sheets of sterilized 
silver-foil are laid over the wound, covering it entirely. Over this 
are placed several layers of sterilized gauze held in place by adhe- 
sive straps ; sterile absorbent cotton is laid over all, and the steril- 
ized six-tailed bandage holds this in place. 

Another simple and effective method of dressing is, first, to place 
half a dozen layers of sterilized gauze over the incision, completely 
covering it, then a pad of absorbent cotton covered with sterilized 
gauze large enough to cover the abdomen, and the whole held in 
place by means of a six-tailed bandage. In all emaciated women 
all inequalities in the abdominal wall are to be filled in with pads 
of sterilized cotton placed over and about the gauze dressing. 



THE TECHNIQUE OF GYNECOLOGICAL OPERATIONS. 65 

The Technique of Vaginal Operations (in which the Peri- 
toneal Cavity is Opened). 

The bowels should be opened by a gentle calomel purge four 
days, if possible, before the operation, and thereafter are to be kept 
regular by compound rhubarb pills given at bed- time. 

If the operation is to be in the forenoon, the rectum is emptied 
by an enema the previous night, and a liquid supper of toast and 
broth given. No food or drink is given in the morning. 

If the operation is to be after one o'clock, the evening enema is 
given, and in the morning early coffee and toast are admissible. 

Preparation of the Field of Operation. — A routine practice is 
to be adopted for all cases. The abdomen should be prepared as 
for an abdominal section. It is necessary to prepare the abdomen, 
as the operator may be at any time obliged to abandon the vaginal 
method and adopt the abdominal. The day before the operation 
the vagina is filled with a wet bichloride-of-mercury dressing. The 
pnbes and vulva may be shaved either before or after the patient 
takes ether. 

The operator cleanses the vagina after the patient is on the ope- 
rating-table. The vagina, vulva, and buttocks should be cleansed 
with soap and hot water by means of a long brush, sterilized, such as 
jewellers use to clean watches. The vulva is further rendered sterile 
by means of ether, alcohol, and bichloride-of-mercury solution. 
All parts about the field of operation are then covered by sterilized 
towels. A diaphragm composed of three or four thicknesses of 
gauze laid over the vulva, inner surfaces of the thighs, buttocks, 
and pubis, reaching well clown below the border of the table, covers 
all. Through a slit in the centre of this the operation is per- 
formed. The bladder is emptied by the operator by means of a 
sterilized catheter prior to the disinfection of the vagina. The 
operator then disinfects himself again. 

General Details for all Operations. 
During the progress of all operations the sponges should be 
handled by one nurse alone, who has no other duty to perform. 
She should pass the sponges directly to the operator or assistant, 
and should take them again for cleansing directly from his hands. 
A sponge should never be laid down anywhere, excepting in its 
basin of water, by either nurse or surgeon or assistant. In no 
other way can one be sure they will not become contaminated. 



66 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

Instruments should be placed in trays convenient to the operator 
or assistant, and should be handled by no one else. Like sponges, 
they should always be returned to their trays when not in imme- 
diate use. 

Needles, ligatures, sutures, etc. should be handled exclusively by 
the nurse or assistant assigned to that duty, and, like everything 
else, should pass directly from his or her hands to those of theJ 
operator or assistant alone. 

Every assistant or nurse should be assigned to an especial duty, 
and under no circumstances be allowed to depart from it ; nor 
should any visitor in the operating room be allowed to at any time 
touch any person or article in the room under any circumstances. 
Clean linen " dusters " should be provided for visitors, in the pockets 
of which they should be requested to keep their hands. 

Should it become necessary for a nurse to open a door, a window, 
pick up a bucket, or in any way risk contamination of her hands, 
she should first take up a sterilized towel and with it in her hand 
perform the duty : the towel should at once be thrown on the floor, 
so as not to be again used. 

As in all operations of any kind whatsoever, all organs of the 
body should be given a thorough overhauling, else some lesion 
which may form a contraindication for anesthesia and operation 
may exist. More especially should the kidneys be carefully exam- 
ined for the purpose of eliminating the presence of albumin or 
renal casts. 

Saline Infusion. 

In patients who have been profoundly septic for a long time or 
have nephritis, or because of hemorrhage either before, during, or 
after an operation, it may be found necessary to fill the vessels with 
saline solution. This acts beneficially in three ways : it washes into 
the general circulation the leukocytes which are in a state of stasis, 
thereby increasing the resistant power of every tissue ; it supplies 
fluid which has been lost by inability to assimilate drink or by 
hemorrhage ; and it so dilutes the blood that damaged kidneys can 
eliminate the deleterious salts which should be removed from the 
blood. There are two ways of administering the fluid — subcutane- 
ously and intravenously. 

The essentials to the operations are — an eight-ounce glass fun- 
nel, six feet of rubber-tubing attached to the funnel, and a large 
aspirating needle or small trocar. A 1 per cent, solution of ordi- 






THE TECHNIQUE OF GYNECOLOGICAL OPERATIONS. 67 

nary table salt is made and filtered through plain cotton or several 
thicknesses of closely woven muslin (unstarched). The salt solution 
is boiled in a perfectly clean kettle, and cooled to about 110° F. by 
setting the kettle in iced water. In testing the solution the degree 
of heat should be determined by passing a small portion of the solu- 
tion over the naked arm. When once the solution is made, the 
kettle should be kept closed. The infusion apparatus should be 
boiled in plain water, not soda solution, for twelve minutes. 

Subcutaneous Infusion. — The operator carefully sterilizes his 
hands. He then washes with 2 per cent, lysol or bichloride-of-mer- 
cury solution a small spot of skin over the margin of the latissimus 
dorsi muscles at the level of the nipples. A cone-shaped piece of 
ice is dipped into salt and pressed against the cleansed skin. When 
the skin freezes it is incised with a sharp scalpel. Filling the funnel 
with salt solution, the operator raises it, and allows the solution to 
flow through the cannula, and while the stream is running he inserts 
the cannula or needle just beneath the skin or under the breast. As 
the fluid flows, a large swelling forms. An assistant watches the 
pulse. Often to encourage the flow it is necessary to strip the tube 
with the fingers from above downward. The procedure can be 
repeated each twelve hours so long as deemed advisable. From 
eight ounces to a pint can be thus introduced into the subcutaneous 
tissues at each puncture-point. 

Intravenous Infusion. — An assistant holds the bared arm of the 
patient and constricts the veins above the elbow by circling the arm 
with his hand. The hollow of the elbow is sterilized. The injec- 
tion is made into the median basilic vein where it crosses the middle 
of the bend of the elbow. For a space of a half inch alongside, 
not over, the vein the skin is carefully incised. As soon as the ope- 
rator passes entirely through the skin he comes to the loose subcu- 
taneous tissue, which may be filled with fat lobules. Having passed 
through the skin, the cut is made to slide over the centre of the vein 
and the edges retracted. The operator grasps the distal portion of 
the exposed vein with artery forceps and lifts the vessel up. He 
separates the vessel from underlying tissues by blunt dissection, and 
grasps the wall of the vein with artery forceps above the first pair. 
He must hold the proximal part of the vein securely, yet must not 
obliterate the calibre. The vein is then cut entirely across. The 
mouth of the proximal end is grasped with mouse-toothed forceps 
and the assistant starts the flow of saline solution through the can- 



68 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

nula. After all bubbles have escaped and the fluid flows at a proper 
temperature, the operator inserts the cannula into the proximal 
end of the severed vein and holds it there, while the assistant releases 
his grasp around the arm above. The funnel should be held four 
feet above the patient, and should be refilled before entirely empty. 
While the assistant fills the funnel the operator compresses the tube 
lest air-bubbles be drawn into the vein. In this way from one pint 
to two quarts of fluid can be inserted into the vein. Having com- 
pleted the operation, the proximal and distal ends of the vein are 
ligated. The skin wound may be sutured or left open under an iodo- 
form-gauze dressing, according to the cleanliness of the technique. 



MENSTRUATION AND ITS ANOMALIES. 



Menstruation. 

Definition. — The flow of the menses. A periodic function of 
the female generative organs, consisting in a bloody discharge from 
the uterus. It occurs, on the average, every twenty-eight days, and 
continues from one to six days. Menstruations extend over from 
thirty to thirty-five years of woman's life, and this time is known 
as the period of the "genital life." 

Synonyms. — It is popularly known by the following names or 
expressions: "being unwell," "periods," "turns," "courses," "flow- 
ers," "terms," "sickness," "the reds," "menstrual flux," "troubles," 
"monthly illness," "the flow," "the catamenia," "the monthly puri- 
fication." 

Regularity and Duration. — The average time of the reap- 
pearance of menstruation, counting from the beginning of one 
period to that of the succeeding one, is twenty-eight days. This 
interval is not fixed ; it is very elastic. In many cases it is less 
than twenty-eight days ; in others, longer than four weeks, appear- 
ing however with punctuality. One woman may menstruate every 
calendar month or twelve times each year, while another may men- 
struate sixteen or seventeen times each year, yet both may be normal. 
Again, a woman may always have irregular intervals between her 
flowing and yet be perfectly well. A woman in good health, who 
asserted that her menses always appeared regularly, was directed to 
keep an accurate record of the intervals for one year. At the end 
of that time her report showed that they varied from twenty-four to 
thirty-five days. Being healthy and never having had her atten- 
tion directed to the matter before, she had always called herself 
regular. The general rule, however, is that women menstruate 
every twenty-eight days. 

Occasionally the menses appear at very irregular periods — e. g. 
two to five times in one year. One woman, in apparently good 
health, gave a history of an average of only two menstruations 



70 AN AMERICAN TEXT- BOOK OF GYNECOLOGY. 

annually for over seventeen years, her flow having no regularity ; 
the two periods sometimes occurred within thirty days, no other 
menstrual flux appearing till the following year. Such cases are 
altogether unusual. A few women have been known to menstruate 
only in warm weather. 

A normal menstruation may last from one to six days. Each 
woman is a rule unto herself in the matter of the duration of her 
monthly flow. Whatever her experience in this direction may 
be when she is in an otherwise healthy condition, is normal for 
her — a condition that cannot necessarily be laid down as the nor- 
mal one for another woman. Three stages characterize the flow : 
1st, the fluid is slimy and odorous, colored light or dark red by a 
small number of blood-corpuscles in a proportionately large amount 
of mucus ; 2d, the fluid is almost pure blood ; 3d, the fluid becomes 
lighter colored, its constituents being similar to those of the first 
stage. Exceptionally, the third stage is followed by another flow 
of pure blood lasting one day, to be followed by a light-colored 
mucus discharge, lasting thirty-six to forty-eight hours. 

Very commonly, in girlhood, the approaching menstruation is 
heralded for two or three years by certain disorders occurring 
with monthly periodicity. It is not at all rare at this age to meet 
with very obstinate symptoms, such as headaches, epileptic fits, 
digestive disorders, or cutaneous affections, for whose treatment the 
usual remedies fail. The writer encountered in a girl of fifteen 
years of age, before the menses had appeared, an attack of facial 
erysipelas which recurred every twenty-eight days for a period of 
fourteen months. For such maladies medical men are in the habit 
of prophesying a cure when menstruation is established — a fact that 
experience verifies. As the time for the appearance of £he flow 
draws nigh the nervous system becomes more irritable ; there is 
general uneasiness and an alteration of the moral character. Com- 
monly there is much languor, flushing, sensation of fulness, and 
disturbed or unnatural, heavy sleep, these symptoms continuing 
for a longer or shorter period. Immediately preceding the first 
flow there is much pain and weight, with fulness in the head and 
pelvis, and throbbing and swelling of the mammae. Often the dis- 
charge is not at all regular to the month for the first half year or 
so, passing over a month or longer ; yet the usual prodromic dis- 
turbances, enumerated above, are found to observe the lunar inter- 
vals quite regularly. In many young women the precursory 



PLATE XJ. 



Fig-. 4. 






? & 






^ ^°© 







Microscopic view of Menstrual Fluid at diiVcre.it periods of Menstruation (Figs, 
of Endometrium cast off ten days after .Menstruation 1 pj 



, I) Kni-mcnis 



MENSTRUATION AND ITS ANOMALIES. 71 

phenomena above mentioned are so slight or evanescent that no 
attention is paid to them. Slight choreic movements and an ele- 
vation of temperature may accompany the first menstruation. 

The menses usually appear in American women at the fourteenth 
year. The colder the climate the later does menstruation become 
established. The average time of its appearance in temperate cli- 
mates has been set at between twelve and eighteen years, from 
thirteen to twenty- one for cold climates, and from eleven to fifteen 
for hot climates. City girls menstruate earlier than girls who live 
in the country. Brunettes are said to menstruate earlier than 
blondes. Precocious menstruation is often seen at ten, nine, and 
even as early as eight years of age. Cases of much earlier appear- 
ance have been frequently reported. One case is recorded in which 
the menses appeared within the " first few months after birth " 
(Charpentier) . On the contrary, there are women in whom men- 
struation is delayed. 

Menopause, or Change of Life. 

Definition. — The cessation of the menses is called the " meno- 
pause." By the term is meant that period in a woman's life when 
she stops menstruating. 

Synonyms. — Its synonyms are the " critical time," the " turn," 
the " change of life," the " dodging-point," and the " climacteric." 

Description. — The menopause includes a very elastic period of 
time in a woman's life. It may be very brief and abrupt, or it may 
extend over a long period of time, as three or more years. The 
typical development of the menopause consists in the irregular 
occurrence of the menstrual flow. Instead of appearing at the 
usual time, it will be delayed a few days or will pass over to 
a second period or longer, and then occur about as usual in the 
amount of the flow and accompanying symptoms. This menstrua- 
tion will be followed by similar irregularity, or perhaps by one or 
more flowings, regular as to the intermenstrual interval and to the 
amount of the discharge and with the usual accompanying symp- 
toms. This irregularity of the discharge may continue for a period 
of over one year, or to three, or even five years, when the flow 
disappears entirely, never to be seen again. 

Occasionally it happens that women, menstruating regularly, 
almost to the day, experience a sudden and complete disappearance 






72 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

of this function. Such an experience in the change of life is 
altogether exceptional. 

The menopause may be said to include all of that period of time, 
intervening between the beginning irregularity of menstruation and 
the complete cessation of the flow, with the subsequent restoration 
of health. At this time the vague nervous symptoms which accom- 
pany the disturbances incident to the change of life are ushered 
in. Where these exist, depending upon the approaching menopause, 
they must be included in this period. During this space of time, 
very often, different symptoms are produced in different women. 

These symptoms include manifestations or perversions, especially 
of the nervous system, and are shown in the form of vertigo, faint- 
ness, flushes, cold hands and feet ; in the digestive system, by gastric 
fermentative dyspepsia, tympanites, constipation or diarrhea ; in 
the circulatory system, by palpitation, syncope, and vicarious hem- 
orrhages ; in the cutaneous system, by sudden, severe and often- 
times offensive sweatings ; in the mental realm, by loss of memory, 
irritability of temper, fear, apprehension, melancholia, and hysteria ; 
by changes in the physique, the development of hair on the chin 
and face, flaccidity of the breasts, and the great increase of omental 
and abdominal fat. Very many other symptoms might be men- 
tioned. Pelvic and lumbar pains, such eruptive conditions of the 
skin as appear at the age of puberty, pruritus vulva? and colic, are 
often encountered. 

A sallow, chlorotic, or plethoric state, or a nervous condition 
entirely unusual in the patient, may characterize her at this period. 
Leucorrhea is one of the most common symptoms during the 
change of life. An awakening of sexual desire, quite unknown 
during previous years, which is often looked upon with a sense of 
shame and degradation by its possessor, is not uncommon in women 
undergoing the menopause. 

It must be distinctly understood that the symptoms enumerated 
above are not all to be found in every woman at the change of 
life. They include the principal disturbances observed at this 
time in a large number of women. The ones most commonly en- 
countered are the manifestations exhibited by the nervous system. 
The one symptom of all those enumerated that seems to be well- 
nigh universally experienced at this period, is flushes; few women 
escape them. Next to them in frequency may be mentioned the 
disturbances of the alimentary tract. 



MENSTRUATION AND ITS ANOMALIES. 73 

Some women experience a multitude of these symptoms, while 
others seem to escape nearly all of them. Their cause would 
seem to reside in the sudden congestions of certain areas of the 
nervous system, through the non-escape of the customary monthly 
bloody discharge. Their relief is often experienced by vicarious 
hemorrhages from the nasal mucous membranes, from hemorrhoids, 
by a free diarrhea, or a profuse leucorrhea. 

The sudden cessation of the menses is frequently associated with 
an abrupt invasion of the nervous system, as fright, shock — mental 
or moral — or by some septic malady, as uterine and tubal disease, 
the essential fevers, gout, or rheumatism. 

The symptoms accompanying artificial menopause following the 
removal of the uterine appendages are usually more prolonged, 
lasting often for years. The change is more stormy, all the symp- 
toms being exaggerated. 

A stormy, irregular, or delayed menopause should excite in the 
attending physician the suspicion of some pathological condition. 
This is the time of a woman's life when malignant disease of the 
uterus or its appendages is most likely to manifest itself, and usu- 
ally the first indication that there is any abnormal condition, is seen 
in the behavior of the establishment of the menopause. When 
this has once become established, all the tissues being healthy, there 
should never be a return of the bloody show. Not only should 
the periodical bleeding cease, but all vaginal discharges become 
abolished. If uterine bleeding occurs after the establishment of 
this condition, one of two diseases is most likely to be found — 
either fibroma or malignancy, with the chances largely in favor of 
malignancy, especially if the woman be a multipara. In such cases 
the attending physician should carefully exclude these conditions 
by physical and microscopical examinations. 

The importance of carefully watching a woman through this 
stage of her life cannot be dwelt upon too emphatically. It is 
commonly the practice for physicians to attribute all the ills and 
complaints of such a patient to the menopause. If untoward and 
unusual symptoms appear, they must be studied carefully and their 
cause discovered if possible. Whatever pathological condition is 
found must be dealt with as it would be at any other period of 
a woman's life. 

The time of the cessation varies with the climate, to a certain 
extent ; the colder the climate, the later does the menopause occur. 



74 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

The average time of the termination of a woman's menstrual life 
is in her fifth decennium. Variations from this, in recorded in- 
stances, extend from the twenty-second to the eighty-second year. 
Such extremes are altogether exceptional and unusual. 

Women who begin early in life to menstruate usually pass the 
"climacteric" late in life. Those who begin late to menstruate pass 
the menopause comparatively early. Exceptions to both these 
statements exist, but they compass the rule in a large range of 
observations. 

Heredity seems not to be free from influence in determining the 
time of the menopause. As the mother was in this particular, so 
the daughters are very apt to be. Compliances with this rule are 
more numerous than are the exceptions. 

Pathology. — The involutional changes in the pelvic organs at 
the menopause are precisely the reverse of what is seen at puberty. 
The vulva becomes flattened and shrivelled through absorption of 
its subcutaneous fat. The dimensions of the vagina become con- 
tracted in every direction, and, in the majority of women, the hour- 
glass contraction is seen at the junction of the middle and upper 
thirds of this canal. The uterine walls atrophy, the cavity dimin- 
ishes, and the cervix contracts greatly, sometimes almost disap- 
pearing. The Fallopian tubes diminish in size in all dimensions 
and even become obliterated. The ovaries shrivel and shrink in 
every diameter, even to the point, apparently, of their complete 
disappearance. Their envelope becomes wrinkled and folded in, 
contracting and pinching the walls of the Graafian follicles, which 
appear as little grayish pouches. The mammary glands shrivel 
and become greatly flattened in the majority of women. 

Diagnosis. — It is an easy matter to make a diagnosis of the 
menopause. There is one pathognomonic indication of the pres- 
ence of this condition which is invariably found in all cases. If 
every disease or condition requiring the skill of a physician had 
but one symptom so clearly pathognomonic as the climacteric pos- 
sesses, the practice of medicine would be infinitely easy. In all 
cases of the change of life this one indication, never absent, is the 
interruption to the regular and stated appearance of the menstrual 
flow. This interruption does not always present itself in the same 
manner. It usually appears in lapses, of greater or lesser degree, in 
the appearance of the flow. The habit of each woman as to the regu- 
larity of her menstruation must be learned, and from that habit 



MENSTRUATION AND ITS ANOMALIES. 75 

comparison instituted. Women often consult their physicians, sup- 
posing themselves to be passing through this period of their lives, 
so much feared, when inquiry reveals the fact that their menstru- 
ations are perfectly normal in the date of appearance, the amount 
of discharge, and the accompanying symptoms. Such patients, irre- 
spective of their age, can always be assured that the much-dreaded 
period has not yet arrived. 

The symptoms of the climacteric are multiform. The principal 
ones have been enumerated under the description. The test of the 
pathognomonic value of these symptoms is shown by the relief 
experienced by a profuse flow after a protracted amenorrhea of sev- 
eral weeks or months. These flows relieve the congestive state 
which is so productive of perturbed functional conditions. Follow- 
ing them is a cessation of a number of those symptoms that have 
become gradually established during the period of amenorrhea. 

Organic diseases must carefully be excluded in the diagnosis of 
the menopause. For instance, to attribute a pyrosis and vomiting 
to the nervous aspect of the change of life, when an incipient gastric 
carcinoma is present, would be an unfortunate exhibition of diagnos- 
tic carelessness. The most careful and painstaking examination 
should be made in every case. Methodical examination of each 
organ is demanded. In this way only can organic disease wholly 
foreign to the climacteric be excluded. Failure to detect incipient 
pathological developments may result in disaster and death. 

Prognosis. — The prognosis is generally good. Where the germs 
of disease have existed previously, organic disorders may be started 
into activity and developed at this time. This is perhaps especially 
true of dysplasmatic growths. It is frequently observed, in highly 
neurotic women, in whom an hereditary taint of insanity has been 
previously recognized, that this disorder may develop at this time. 

Generally speaking, the prognosis is satisfactory. It is excep- 
tional that the troubles of the menopause are anything more than 
temporarily active. 

Treatment. — The treatment is governed wholly by the indica- 
tions present, and thus becomes symptomatic. 

The axiomatic principle of the treatment of all disorders holds 
true in the management of the menopause, and that is to make 
waste and repair as nearly equal as professional skill will permit. 
This involves a most careful attention to the secretions, the excre- 
tions, and the blood state. Women suffering from a deficiency of 



76 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

secretions, from a retention of excretions, or from impoverished blood, 
are sure to present many serious symptoms at the menopause. 

The state of the alimentary tract demands particular attention. 
The fermentative dyspepsias are productive of more symptoms at 
the change of life than at any other period. Gastric lavations, cre- 
asote, salicine, corrosive sublimate, and other antiseptic remedies are 
indicated. A tender liver and chronic constipation call for daily 
laxatives. Cascara, compound liquorice powder, Hunyadi salts, 
Rochelle salts, and other salines are highly useful. The salines 
are especially indicated when anemia is not too profound, because 
their depletory action lessens congestion, an effect greatly needed at 
this period of a woman's life. Daily defecation should be insisted 
upon. Constipation, producing numberless reflexes and leading 
to fecal anemia, is a most deplorable condition and should not be 
tolerated. 

The renal system is carefully to be considered. Renal insuf- 
ficiency must be corrected. Lithemia may be eliminated by the 
free use of lithic-acid solvents, as the citrate of potassium or lithium. 
Lithic acid is the parent of many neuralgias and mucous-membrane 
disorders. Ignoring its presence frequently defeats the physician's 
treatment. 

The cutaneous system should not be ignored. Frequent warm 
baths are useful. Above all, the skin should be protected from 
changes of temperature by suitable underwear. Chilling the sur- 
face of the body facilitates many minor internal congestions, which 
can be avoided by proper attention to the clothing. The systematic 
use of general massage and Turkish baths invites the blood to 
the skin, tending thus to equalize the circulation and to relieve 
internal congestions. 

The condition of the heart demands attention in many cases. 
One of the most common complaints is paroxysmal tachycardia, 
which comes and goes erratically, lasting when present from min- 
utes to days, the intervals of absence varying similarly. The 
attacks come on without warning, even during sleep, accompanied 
by violent action of the heart, pulsation of the carotids and aorta, 
cephalalgia, and flushes. A consuming fear of apoplexy or sudden 
death prostrates the patient. Her general state becomes demoral- 
ized by repetitions of the attack. Sleep is disturbed by horrible 
dreams, and she becomes the victim of general nervous depression. 
Occasionally oedema without albuminuria is observed. These at- 



MENSTRUATION AND ITS ANOMALIES. 77 

tacks generally do not depend upon organic cardiac disease, but 
upon local congestion of the heart-centre in the medulla oblongata, 
doubtless a reflex, in the majority of cases, from the alimentary 
tract. This statement is confirmed by the relief following the use 
of remedies addressed to the digestive apparatus. 

All cases complicated with cardiac symptoms demand a most 
careful examination of the heart. Severe and long-continued men- 
orrhagia is often associated with feeble heart. A fatty heart, as 
well as a feeble heart, is attended with impeded circulation, as 
is shown by oedema, albuminuria, dyspnea, and palpitation. It is 
a grave error to attribute such symptoms to nervousness or hys- 
teria or to the change of life. 

The blood state frequently demands attention. Anemia is often 
caused by the dyspepsias and constipation. When it arises from 
hemorrhages, especial attention should be given to the most absolute 
quietude in bed and to hemostatic measures. Blood-poverty is the 
cause frequently of the most annoying and obstinate functional dis- 
turbances of the nervous system ; hence its correction is of the 
utmost importance. Where plethora exists venesection is in many 
cases most urgently demanded. Bloodletting is a lost art to-day; 
where it is inadmissible, saline cathartics can freely be used. Bleed- 
ing from the arm or from the cervix uteri gives more speedy and 
protracted relief than any other measure ; it rarely does harm. 
Leeches can be used over the region of the round ligament at the 
external abdominal ring, or at the anus, in cases of ovarian or uterine 
congestion. 

Mental therapeutics should not be ignored. The depressing 
emotions exert a deleterious influence on woman at this period of 
life. Hence worry, care, anxiety, and unnecessary responsibilities 
should be cast aside as much as possible. Social diversions, amuse- 
ments, and congenial occupations ought to be encouraged. Oppor- 
tunities for depressing introspection should be guarded against 
sedulously. 

The nervous symptoms so common at this time, as flushes, trem- 
blings, headaches, etc., dependent on local congestion of certain areas 
of the nervous centres, are best relieved by the bromides. These 
agents decongest and benumb, hence their wonderfully satisfactory 
action in women passing through the change of life. The effects 
of these preparations cannot be too highly praised. The choice of a 
bromide is not altogether inconsequential. The ammonium bromide 



78 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

is very speedy in its action, but it is far too evanescent. The potas- 
sium bromide is much slower and more permanent in its effect, but 
its depressant influence on the heart in large doses is objectionable. 
A more pitiable combination than a woman suffering from severe 
nervous manifestations in the menopause, combined with an induced 
cardiac debility, is difficult to imagine. The sodium bromide is 
the best of all bromides to use. It is markedly diuretic and does 
not materially depress the heart. The tendency of the bromides 
to produce acne can be largely averted by the use of arsenic, in 
the form of Fowler's solution, after meals. The effects of the bro- 
mides are wonderful in relieving pains, flushes, nervousness, and 
mild melancholia. Used in combination with camphor, their ana- 
phrodisiac action, where needed, is most gratifying. Too much cau- 
tion against the miscellaneous use of narcotics and diffusible stimuli 
cannot be entertained. The use of opium and chloral is especially 
objectionable, unless the suffering becomes unendurable, when they 
should be used for the briefest period of time and interdicted by 
the physician's specific ordering. The objection to their use is the 
fear of establishing the opium or chloral habit at this impression- 
able time, when a woman will resort to anything to secure relief, 
irrespective of consequences. 

From the foregoing remarks it will be seen that the object of 
therapeutic attack must be sought for, chiefly, outside of the pelvic 
organs. It is understood that uterine, tubal, and ovarian con- 
gestions, when found, are to be treated secundum artem. The 
remainder of the treatment of women at the climacteric is purely 
symptomatic. There is no specific treatment of the menopause. 

Composition and Quantity of the Menstrual Discharge. — The 
flow at first is mucous in character, gradually changing color till 
it becomes distinctively sanguineous. It has an acid reaction from 
phosphoric and lactic acids ; a peculiar odor, due to fatty acids ; and 
consists of blood (venous), serum, ciliated vaginal epithelium, and 
the debris of an endometrium necrosis, mixed with pigment, broken- 
down blood-disks, and granular detritus. It is ordinarily non- 
coagulable, owing to the mucus that it contains. When there is 
disproportionately too large a quantity of blood present, as in men- 
orrhagia, coagulation is common. Hence, when women flow too 
freely, as from a diseased condition of the pelvic organs, it is exceed- 
ingly common to see coagula discharged ; therefore, the attempt to 



MENSTRUATION AND ITS ANOMALIES. 79 

prove that coagula in the menses indicate an abortion is fallacious. 
At first in normal women the discharge is pale, at the height of the 
flow, deep red, and toward the last, again pale. In chlorotic women 
is seen the pale flow, or menstruatio alba. It is erroneous to say 
that the discharge is poisonous, having an injurious effect on living 
things, as men, animals, and plants. Its mucous element possesses 
at times an injurious and irritating effect on the male urethra, 
causing a peculiar chronic urethritis. One can but be impressed 
by the wisdom of the Mosaic edict forbidding cohabitation with a 
menstruating woman. 

Some women are said to be free from the function of menstrua- 
tion. Close inquiry, however, usually reveals the fact of a periodic 
white discharge occurring from their genital organs. 

The amount of the discharge varies from four to eight ounces. 
The recorded observations of extremes vary from two to eighteen 
ounces. Many conditions cause variations in the amount in the 
same women, as health, diet, exercise, climate, and sexual excesses : 
consequently there is nothing fixed. Hippocrates thought the 
Grecian women shed twenty ounces at each period. Galen averred 
that the Romans lost eighteen ounces. Meigs stated fifty years ago 
that many healthy American women lose twenty-one ounces as the 
normal and regular elimination. Such amounts must be regarded 
as far above the average. 

The source of the menstrual discharge is the endometrium. It 
is the consequence of hyperemia of the pelvic organs : the uterus, 
tubes, ovaries, and broad ligaments. The contraction of the mus- 
cular fibres of these organs compresses the veins, retarding the flow 
of blood and increasing the tension in the capillaries, which rupture 
and give rise to the appearance of the menstrual flow. Under the 
influence of this congestion, the volume of the uterus increases a 
quarter, a third, and sometimes more. At this time the pampini- 
form plexus becomes so distended that in lean women it can very 
often be detected by conjoined manipulation. The turgid uterus 
undergoes a true anorthosis. The cervix becomes larger and softer. 
The endometrium swells, becoming folded and mammillated. The 
epithelia become loosened and pushed off. The hypertrophied 
mucous glands become the seat of an abundant secretion. The 
lining membrane of the fundus yields the largest part of the cata- 
menial discharge, because of its looser anatomical texture, while the 
cervical canal, having more resisting vessels, which do not burst, 



80 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

Fig. 




Am 






w 






Vertical Section through Normal Mucous Membrane of the Uterus: e, columnar epithelium, the cilia not 
represented ; gg, utricular glands ; cl, ct, connective tissue ; w, blood-vessels ; mm, muscularis mucosae. 

yields a purely mucous discharge. The canals of the tubes are some- 
times filled with blood likewise, thus increasing the menstrual flow. 
The vagina becomes darker in color and the increased vascularity 
causes the mucous membrane to swell and to shed an increased 

Fig. 29. 




Mcn.slruiil I'.iMloniclnuin. 



MENSTRUATION AND ITS ANOMALIES. 81 

amount of mucus, having more or less odor. The vulva often 
becomes tumefied, and is sometimes the seat of mild pruritus, thus 
explaining the frequently experienced micturition. 

The menstrual discharge, composed of blood, mucus, serum, 
epithelia, and the debris of granular detritus, is a very complex 
fluid. The endometrium, undergoing rapid degeneration, is shed 
in patches and shreds. It is called the decidua menstrualis. 
This decidua is developed from the upper part of the uterine 
mucous membrane, and does not involve the Fallopian tubes or 
cervix uteri. The shedding and the redevelopment of this 
decidua are matters involving much speculation. It is generally 
conceded at present that it is cast off in fragments — sometimes in 
one or two large pieces. Within a few days it is re-formed, 
and its shedding again repeated. Should conception occur, the 
decidua menstrualis becomes the decidua vera. The decidua men- 
strualis is a very important factor in membranous dysmenorrhea. 

The syndroma menstrualis includes the attendant phenomena 
of a menstruation, preceding and accompanying it. They are both 
general and local. 

General. — The entire glandular system is stimulated. The sudo- 
riparous glands secrete increasedly, and in many women the odor 
of the perspiration becomes characteristically pungent. The bron- 
chial glands secrete more actively. The alimentary secretions are 
increased in many women to such a degree that they are inclined 
to eat voraciously, while many other women have diarrhea at the 
outset of the menstrual flow. Pigmentary deposit under the eyes 
and on the nipples, genitals, face, and neck is common. An 
increased deposit of fat beneath the skin in most parts of the body 
very commonly accompanies the establishment of the genital life of 
woman, and all the contours become more rounded and graceful. 
The volume of blood is augmented and cardiac action and arterial 
tension are increased. Malaise and lassitude supervene. Many 
girls experience a nervousness bordering upon uncontrollableness. 
Alternate subjective sensations of heat and cold are often expe- 
rienced. 

Local. — The vulva becomes more prominent and filled out. The 
uterus and vagina enlarge. Pubic and axillary hair appear. The 
mammary glands increase in size and become sensitive, the nip- 
ples grow larger and darker. The pelvis becomes broader. The 
mental changes exhibit the occurrence of sexual desires, by the 

6 



82 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

development of more reserve and the abandonment of hoydenish 
ways. Increased micturitions, yawnings, cramps, and hiccough are 
common. Hemorrhages occurring at the same time from other parts 
are known as supplemental menstruation. Piles, if they exist, are 
more congested and nsevi are deeper colored. 

Vicarious or ectopic menstruation, or xenomenia, consists of a 
bloody discharge from some other organ than the uterus, either 
with or without a minimum menstrual flow at the same time. 
When the minimum menstrual discharge occurs, vicarious or 
supplementary menses takes place from the lungs, the nose, the 
alimentary canal, or the subcutaneous cellular tissue. Where there 
is no uterine hemorrhage, the vicarious menstruation may arise 
from the lungs, nose, alimentary canal, mouth, the surface of a sore, 
from an erectile tumor, the skin, the conjunctiva, the nipples, the 
gums, the bladder, the ear, or the stump of an ovarian cyst. The 
nose is the most frequent seat of vicarious menstruation. In men- 
strual hemoptysis it is of vast importance to exclude tuberculosis. 
Occurring from the skin, vicarious menstruation is called " hemati- 
drosis " or " sweating blood." 

Retention of menses, or hematometra, is an accumulation of the 
menstrual flow within the uterus, its exit being prevented by a 
defect of formation of the uterus, cervix, vagina, or vulva. Such 
cases may be denominated apparent amenorrhea. At first they are 
regarded as amenorrhea. Much pain characterizes them, and they 
may be regarded as practically to occupy a place between amen- 
orrhea and dysmenorrhea. Every month the patient presents 
painful disturbance centering in the hypogastrium. Cephalalgia 
may occur, with flushing, accelerated pulse, emesis, intestinal and 
vesical disturbance, and leg pains. In a few days these phenomena 
subside, only to reappear in about twenty-eight days. The general 
health at length deteriorates. Sooner or later the abdomen swells. 
A mild degree of sepsis may occur, commonly hastening to a climax. 
Soon thereafter the physician is called to investigate, and an atresia 
is discovered. 

Cases of uterus bicornis have been reported where one cornu was 
patulous while an atresia of the other existed, causing a retention 
of the menses. Dec6s reported in 1854 such a case wherein rupture 
and a fatal peritonitis occurred. 

Cases of retention may be congenital or acquired. In the former 
there is some congenital defect or some condition acquired in child- 



MENSTRUATION AND ITS ANOMALIES. 83 

hood. In the latter the atresia most commonly follows parturition 
or syphilitic invasion. 

The intermenstrual molimen consists of the presence, in some 
women, of all the discomforts of a menstruation without a bloody 
discharge, occurring midway between two monthly periods. Many 
women experience it in full intensity, while others have it in only 
a slight degree. Oftentimes therapeutic measures are necessary to 
control these intervening pains. 

Menstruation and Ovulation. — Till within a few T years these two 
functions were considered as one, the flow being regarded as the 
external manifestation of ovulation. At present this view is opposed 
by many writers. Formerly no one felt disposed to question the 
accepted theory that the ovaries controlled menstruation. After the 
removal of the ovaries became a common operation, it was found 
that nearly all women undergoing this procedure ceased menstruat- 
ing, and then the conclusion was confirmed that the ovaries pre- 
sided over the function of menstruation. Later it was observed 
that occasionally a woman was found who continued to menstruate 
after oophorectomy. This led to questionings which threatened to 
uproot the time-honored theory of the interdependence of menstrua- 
tion and ovulation. Very soon thereafter one prominent laparoto- 
mist boldly announced his belief that the Fallopian tubes controlled 
the function of menstruation, his argument being, that when the 
ovaries and tubes were completely removed, menstruation never 
appeared thereafter. He thus explained that menstruation after 
oophorectomy occurred because not all of the tubes was removed. 
In time it w T as found that even after the removal of ovaries and 
tubes cases of menstruation or of monthly flow were occasionally 
reported ; hence the true explanation of the cause of menstruation 
seemed not to have been supplied. Further speculation followed. 
The latest theory of causation advanced, is, that neither the ovaries 
nor the tubes control menstruation. Instead, it is the tubo-uterine 
plexus of sympathetic nerves which causes the appearance of the 
menses. Removal of the ovaries does not always annihilate the 
integrity of this plexus, nor does every case of removal of the tubes ; 
therefore where this plexus remains uninjured the monthly flow 
will continue to appear. Speculation on this much-mooted question 
is still rife. The following statements may be accepted as the status 
of professional opinion on this subject at this time: 1. That ovu- 
lation and menstruation are closely associated, but not necessarily 



84 AN AMERICAN TEXT- BO OK OF GYNECOLOGY. 

interdependent; 2. That ovulation may occur without menstruation; 
3. That conception very often occurs without menstruation. 

Pertinent to the last statement may be mentioned the fact that 
many women go for years without menstruating, while they are 
bearing children in rapid succession and suckling them. One 
case, reported in 1879, showed that a peasant-woman married 
before menstruation began, became pregnant and bore and suckled 
sixteen children in the succeeding twenty-one years, when, at the 
age of thirty-six, she menstruated for the first time. Afterward in 
her widowhood she menstruated regularly. It is claimed that ova 
are developed in the earliest infancy, during lactation, and even after 
the menopause. Evidence has repeatedly been adduced, in reported 
cases, of ovulation occurring during pregnancy. Facts such as these 
supply irrefragable evidence that ovulation occurs without produ- 
cing menstruation. The final settlement of the relation existing 
between menstruation and ovulation is still waiting unassailable 
demonstration. 

Menstruation during Pregnancy. — When a woman is pregnant 
her menstruation does not appear ; that is a rule, to which, how- 
ever, there are exceptions. The exceptions are atypical : some 
women menstruate once after conception, some twice, and others 
oftener. Whether the flux is a pure and simple menstrual flow 
has perhaps been questioned, but the fact is indisputable that it 
has appeared promptly on time and has acted just like a genuine 
menstrual flow. Such discharges of blood have been called " acci- 
dental hemorrhages," and not the typical bloody flow of menstrua- 
ation. The writer recalls a woman whom he has attended in five 
out of her six confinements, and in whom the calculation of the 
time of her delivery was always computed from the date of quick- 
ening, it being impossible to determine when conception occurred, 
because she always had her monthly flow up to the fifth month 
of gestation. 

The decidua vera and the decidua rcflexa do not coalesce and 
occupy the entire uterine cavity till the end of the third month of 
gestation. Till that time it is easily understood whence arises the 
How — namely, from the uninvaded endometrium. After the third 
month, however, the menstrual flow must arise from the cervical 
canal, and it will be small in quantity — a fact which comports with 
observations. These remarks in no way apply to cases of bloody flow 
in pregnant women who have uterine cancer, an inflammatory or 



MENSTRUATION AND ITS ANOMALIES. 85 

congested cervix, a polypus or cardiac disease, nor to cases of extra- 
uterine pregnancy. Cases are related in which patients habitually 
menstruate only when pregnant. That a woman can menstruate 
and ovulate after fecundation is shown by superfetation. 

Management of Menstruating Women. 

Physicians should instruct mothers to secure rest and quietude 
for the girl entering on her menstrual experience. Ignorance of 
this function on the part of the girl is highly culpable in the mother. 
Many a young woman has injured herself irreparably by attempts 
at concealing her flow, supposing it to be something disgraceful. 
Thus, washing in cold water, in brooks and streams, has been done 
to conceal a supposably shameful condition. 

Fig. 30. 




Menstrual Pad. 



Where it is practicable the young woman should remain in bed 
two or three days or longer during her menstruation. She is the 
better for such enforced quietude and freedom from the usual wear 
and tear of her nervous energy, incident to active youthfulness, 
at a time when her system is learning to accommodate itself to a 
new experience. Books, magazines, and pictures can entertain her 
during these days of restraint. She becomes accustomed to the 
monthly quietude and accepts it without a murmur. Every woman 
is better off for such resting, and it should, whenever possible, be 
secured for girls, during the first year, at least, of their menstrual 
life. Where it is impracticable, her duties should be rendered as 
light as possible, and everything in the way of severe exertion 
should be avoided. It is, unfortunately, only too often the case 
that no rest nor lessening of arduous duties can be secured to 
young women. Such women grow old too soon. 






86 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

Amenorrhea. 

Definition. — Amenorrhea is the absence of the menses in 
adult women who are not pregnant, have not passed the meno- 
pause, or do not suffer from retention of the menstrual flow. It 
is not, per se, a disease. It results from a variety of causes 
which may affect either the system at large, or the genital organs 
in particular. Thus we may have amenorrhea resulting from 
general as well as from local causes. 

Complete amenorrhea is the total absence of menstruation, whereas 
comparative amenorrhea is that condition in which the menstru- 
ation appears only occasionally. Primary or permanent amenor- 
rhea is the expression used to describe cases wherein menstruation 
has never occurred. Secondary, transitory or accidental amenor- 
rhea has been called suppressio mensium. 

Causes. — To simplify the causation of all amenorrheas the 
etiology may be reduced to the following : 

Normal menstruation requires the following conditions: 

1. A normal condition of the nervous system ; 

2. A normal state of the blood-supply ; 

3. Integrity of the entire genital apparatus. 

With these three conditions in existence a woman will menstru- 
ate normally and regularly. Serious interference with one or more 
of them will produce amenorrhea. 

The nervous system presides over all functions of the body. 
When it is disordered seriously, the functions are in turn seriously 
disordered. Menstruation must be regarded as a reflex act. Any 
break or interference in the cycle of the reflex movement may 
suspend the menstrual flow entirely. Hence amenorrhea may 
arise through defects in the nervous system. 

It is almost unnecessary to state that there must be enough good 
blood present in the system before a woman can menstruate nor- 
mally. Its absence is one of the most prolific causes of the cessation 
of the flow. 

That the entire genital system must be in a normal condition to 
permit menstruation is self-evident. The organs must all be pres- 
ent, free from stenoses and from degenerative structural changes. 
In enumerating the following causes of amenorrhea it will read- 
ily be observed that each bears upon one or more of the three 
conditions. Therefore, bearing them in mind will enable the stu- 



MENSTRUATION AND ITS ANOMALIES. 87 

dent and practitioner to arrange the various causes systematically 
and in order. The popular idea that amenorrhea is productive of 
dangerous constitutional conditions, as consumption, dropsy, chlo- 
rosis, nervous prostration, and the like, will clearly be understood 
to be a reversal of cause and effect. 

Whatever seriously affects the general nutrition may stop the 
menses temporarily. Thus, an attack of typhoid fever or any other 
serious disease may cause amenorrhea for several months. Through 
such illnesses the function of hematosis is impaired, preventing the 
general nutrition of the system. Thus the nervous system with its 
infinite reflexes fails to perform all of its functions. Menstruation, 
doubtless a reflex, shares the neglect whenever the general nervous 
system is not well nourished. The diseases that most frequently 
cause amenorrhea are chlorosis and pulmonary tuberculosis. It is 
produced by the anemia that follows the essential fevers, pneumo- 
nia, Bright's disease, diabetes, morphinism, cancerous or malarial 
cachexia, alcoholism, hydrargyrism, acute or chronic surgical affec- 
tions, and the onset of profound syphilitic invasion. 

Extreme mental emotion, as fright, grief, anxiety, or great anger, 
may suspend the function of menstruation. Women anxious, from 
misconduct, to menstruate, will often fail to do so. Conversely, 
cases of cure by some sudden emotion have been recorded. Pris- 
oners and insane women are often victims. Hysteria gravior is 
frequently characterized by the cessation of the menses. The 
emotional amenorrhea of the newly-married is well known. The 
anxiety of the woman intensely desirous to become a mother will 
cause a cessation of the menses, often accompanied by tympanites. 

Pelvic disorders may cause amenorrhea, as imperfect or rudi- 
mentary development ; absence of the ovaries or uterus ; cystic 
ovarian degeneration ; pelvic peritonitis with its resultant adhe- 
sions, deforming and displacing the general aspect and position of 
the pelvic organs ; acute metritis and endometritis, chronic diseases 
of the uterine parenchyma and parametrium, and hyperinvolution 
of the uterus following pregnancy. 

Girls who, during the period of active development of the gen- 
erative organs, are urged on in intellectual studies without a suf- 
ficiency of active exercise, fresh air and good healthy hygienic 
surroundings, very commonly suffer from amenorrhea. The 
vis nervosa necessary to physical development is perverted and 
expended in mental work, resulting in delayed or imperfectly de- 



88 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

veloped generative organs. Being the last developed, these organs 
are the first to fail in fulfilling their function. 

Great changes in the mode of living often develop this condition. 
Thus, nurses in training-schools at times cease to menstruate for a 
period of two to six months after entering upon their new mode 
of life. There is often a suppression of menstruation following 
a sea-voyage. 

Rapidly increasing obesity with its resultant anemia, insuf- 
ficient exercise, and luxurious living, are all well-recognized causes 
of comparative amenorrhea. 

One of the commonest causes of acute amenorrhea is exposure 
to cold during a menstrual period ; cold bathing, sitting or lying 
in currents of cold air, sitting on cold stone steps, and a change 
of linen, are common modes of such exj^osure. 

Traumatic injuries can also cause this condition. Nearly every 
physician of experience can recall some case of amenorrhea caused 
by a blow or injury. 

Renal insufficiency is often a cause. Embryologically, the 
urinary and the generative organs arise from the mesoblast in the 
ovum. It is an easy matter to understand that interruption to the 
physiological action of one set of these fundamental organs may lead 
to the interruption of that of the other. The logical sequence of 
cause and effect, herein, may be assailed, but the therapeutic proof 
is brilliant and incontestable. The writer has repeatedly seen cases 
of comparative amenorrhea, with no other discernible cause than 
renal insufficiency, corrected by the use of stimulating diuretics. 

Diagnosis. — All cases of amenorrhea must be carefully exam- 
ined, even under complete anesthesia. 

First, it should be definitely settled whether the case is pri- 
mary or secondary. Primary amenorrhea, where menstruation 
has never occurred, at once leads to questioning whether the ute- 
rus, tubes, and ovaries be present in their entirety. If present, 
it becomes necessary to ascertain whether an atresia of the cer- 
vical canal, vagina, or vulva exists. If the prodromic symptoms 
of a menstruation have never been present, the suspicion of the 
absence of one or more of the generative organs will strongly obtain. 
If these prodromic symptoms have been present, repeatedly, at lunar 
intervals, with no succeeding menstrual flow, the suspicion is at once 
excited that an atresia exists, and that the menstrual flow is retained 
within the genital passages. 



sousi 



MENSTRUATION AND ITS ANOMALIES. 89 

If the case be one of secondary amenorrhea, the cause must be 
jht for both within and without the pelvis, Primarily, preg- 
nancy and lactation must be excluded. Within the pelvis there 
may exist hyperinvolution of the uterus following pregnancy — i. e. 
a senile uterus. Acute metritis, acute endometritis, or an intense 
chronic metritis may be found. There may be atrophy or cystic 
degeneration of both ovaries. Pelvic peritonitis may be present. 
Either one or more of these pelvic maladies may cause an amen- 
orrhea, although the reverse usually obtains in the inflammatory 
conditions. 

Without the pelvis will be found the larger proportion of causes 
of the cessation of the menses. Interferences with hematosis through 
disease and perversions of digestion and nutrition, are the common- 
est of all causes of secondary amenorrhea. A careful and minute 
inquiry as to the anamnesis of this condition will lead to the 
particular line of approach of the causal anemia. This inquiry 
should be particular, systematic, and exhaustive, because without 
it the practitioner will only too frequently fail to learn the cause, 
and consequently to institute the proper treatment. 

After securing the completest possible case-history, confirmation 
thereof will be afforded by a thorough physical examination. Some- 
times such an examination will reveal an organic valvular heart- 
lesion, to the astonishment of the physician. If the investigations 
are carried no further the treatment will not include a slowly- 
advancing Bright's disease, for example, which has led to the 
cardiac lesion, and the physician will fail in restoring the menses 
as, perhaps, have other practitioners in the same case. Such physi- 
cal examination should include the entire system; especially the 
thorax and abdomen. Only the superficial observer will confine 
his examination to the pelvis. It is surprising to note how often 
a hydrothorax or a tuberculous kidney will be found as causative 
factors in amenorrhea. The urine should always be analyzed. 
The systematic examiner of his gynecological cases will be aston- 
ished at the discoveries oftentimes in his patients — discoveries that 
have so easily eluded former medical attendants — discoveries that 
shed an entirely new light in the way of cause and effect. 

The prognosis depends entirely upon the cause. Amenorrhea 
from the absence of pelvic organs is incurable. Pulmonary tuber- 
culosis and other incurable disorders, as advanced Bright's disease 
or diabetes, present a gloomy prognosis. In cases of hyperinvo- 



90 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

lution of the uterus the prognosis is unfavorable. Pelvic inflam- 
mations, amenable to treatment, afford a more promising prognosis. 
In short, only where the cause can be removed is there reasonable 
hope of restoring the menstrual flow. 

Treatment. — It must be borne in mind that many cases of 
amenorrhea exist without producing any kind of disturbance of 
health. The absence of menstruation is simply a part of a con- 
stitutional state. There is no local treatment that will re-establish 
this function. In patients rapidly progressing along the way of 
recovery through general treatment, local treatment will often be 
followed by the restoration of the menses, but this is not post hoc 
propter hoc. The uterus can easily be made to bleed, but this 
must not be confounded with menstruation. In truth, we cannot 
predict positively in any given case of amenorrhea that our treat- 
ment will restore the menses. 

Our patient must be regarded as an entity possessed of a multi- 
plicity of organs, and any and all treatment must include their 
functions and interdependence. The moment the physician loses 
sight of this general fact, his treatment becomes the merest empi- 
ricism. The fact ought not to be ignored that a remedy given to 
a woman progressively improving under general treatment, and 
who is about to menstruate, will unjustly be pronounced an effect- 
ive emmenagogue when in reality it had nothing whatever to do 
with the restoration of the menses. It is incontestable that many 
drugs have thus been endowed with a virtue never possessed. 

The cause always determines the treatment. When pregnancy 
exists, no treatment is to be instituted. Upon this point the prac- 
titioner must ever be on his guard. Designing women often con- 
sult the physician for amenorrhea when they know that they are 
pregnant, hoping that something will be done "to bring on their 
courses" and thus interrupt the gestation. In all cases when in 
doubt the physician should either decline to give local examina- 
tions and treatments, or simple tonics may be administered with 
the instruction that the patient return in a month. The patient, 
seeing the object of her desire so far removed, will not call again. 

The necessary anamnesis obtained and examination having 
been made, the point of therapeutic attack will, as a rule, have 
been exposed. Cases amenable to treatment should be treated 
ever and always with the one fundamental object in view — viz., to 
restore the normal physiological balance, and to render waste and 






MENSTRUATION AND ITS ANOMALIES. 91 

repair equal. To this end it is necessary to restore functions where 
needed; to increase the activity of the skin, kidneys, bowels, liver; 
to augment the volume of the blood with hematic remedies ; to 
improve and invigorate the energy of the general circulation by 
out-door exposure and exercise ; to secure the needed daily regen- 
eration of the nervous power by sufficient sleep, and to protect 
from undue exposure an already enfeebled system by a sufficiency 
of simple and sensible clothing. A gynecologist doing this sort 
of work invades the wide domain of the general practitioner. 

A daily laxative, like the extract of cascara sagrada, or the 
compound liquorice powder, at bed-time, and a tonic after meals, 
as the elixir of iron, quinine, strychnia, and phosphorus, or 
arsenic, or the mineral acids, will be required in the majority of 
cases. If renal insufficiency exists, a stimulating diuretic must 
be added to the laxative and tonic. A good diuretic is the com- 
bination of the potassium acetate with digitalis, or a quarter of a 
grain of calomel, before meals, and the effervescing granular salts 
of lithia citrate or carbonate, after meals. 

With the reconstruction of the general health the menses will 
usually return where no organic perversion or defect remains. 

From time immemorial remedies have been vaunted for restor- 
ing the menses. To-day, with an improved knowledge of the 
pathology of amenorrhea, the number of emmenagogue remedies 
has become greatly diminished. Iron, manganese, and electricity 
enjoy the largest amount of favor as possessors of emmenagogue 
properties. Ergot, rue, savine, and the essential oils are now 
rarely used to restore the menstrual flow. 

The use of iron has been mentioned. The binoxide or lac- 
tate of manganese or the permanganate of postassium, in one-grain 
doses, three or four times daily after food, has found favor as an 
emmenagogue ; it is alleged to determine an increased flow of 
blood to the pelvic organs. Santonine, in ten-grain doses at 
bed-time, has been used with success in chlorotic subjects where 
manganese has failed. 

Electricity has been used to restore the menses by a number 
of gynecologists in the past decade. Its successes and failures do 
not yield the most unqualified enthusiasm in its use. Faradism 
may give gratifying results. Static electricity is commended in 
chloro-anemic girls. The continuous current is used with the 
positive pole over the lumbar or iliac regions and the negative 



92 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

pole in the uterine cavity. Thus applied, it often produces an 
uterine hemorrhage, which is not always a true menstruation. In 
cases where the uterine changes, leading up to a menstrual flow, 
are present without apparently sufficient menstrual energy to even- 
tuate in a normal periodical discharge of blood, electricity will 
undoubtedly precipitate the desired result. Unable to determine 
positively the presence of such uterine changes in a given case, 
the use of this agent must more or less be empirical. 

Galvanic intra-uterine stem pessaries are oftentimes efficacious 
in relieving amenorrhea: they consist of alternate beads of zinc 
and copper arranged on a stem. 

Intra-uterine stem pessaries have been successfully employed in 
restoring the menses. The mechanical irritation and cervical dila- 
tation have doubtless contributed to impel more blood to the uterus 
and its adnexa. 

Guaiacum has been strongly recommended in amenorrhea in 
subjects of marked rheumatic diathesis. The well-known action 
of capillary stimulation by this drug doubtless accounts for its 
efficacy in restoring the flow. 

The allegation has been made that as strychnia favors muscu- 
lar contractility, and thus can aid in rupturing the Graafian vesicles 
most advanced toward maturity, it favors ovulation. Its use as an 
emmenagogue in amenorrhea has been favorably reported. 

Sodium salicylate has been successfully employed because of its 
power to produce pelvic congestion. 

Oxalic acid, in half-grain doses three or four times a day, has been 
highly recommended and is very effective. It has been known to 
bring about a miscarriage when accidentally given during pregnancy. 

Indigo has recently been very highly recommended in the treat- 
ment of this condition. It cured 13 out of 14 cases ; the fourteenth 
was a failure because it was a case of pregnancy. Under its use the 
os uteri becomes soft and patulous, admitting the index finger. 

The latest advocated method of treatment of amenorrhea is by 
psychotherapy. Every month brings reports of cures by hypnotism. 
These cures are obtained by the induction of the hypnotic state and 
subsequent suggestion. It is alleged that results truly marvellous 
have been obtained with the expectant attention induced by sug- 
gestion. In the present chaotic condition of the entire subject of 
psychotherapy, the writer is content with barely calling attention to 
hypnotism in this connection. 



MENSTRUATION AND ITS ANOMALIES. 93 

Marriage has been recommended as a suitable stimulant in some 
cases of amenorrhea. In view of the fact that we have no positive 
data upon which to base a prognostic success, such advice is ques- 
tionable; its failure would entail mental misery on both parties to 
the marriage. Whenever we are consulted in regard to the mar- 
riage of an amenorrheic woman, a thorough pelvic examination is 
imperative. Should such a woman marry upon medical advice 
without an examination, she may discover, when too late, that she 
is unfortunately deformed, by the lack of a normal development 
of the generative organs. Such an eventration has led to more 
than one tragic termination. It has also caused tribunals to declare 
nullity of marriage on the ground of error as to the sex of one 
of the parties. 

Amenorrhea is merely a symptom of some general disease, except 
in those rare cases of malfoi*mation, and as such, requires no local 
nor constitutional treatment directed solely to the pelvic organs. In 
the vast majority of cases it causes no trouble whatever, the patient 
applying for treatment simply for the reason that the usual flow has 
failed to appear. The mere absence of the menses should be ig- 
nored, especially when no other symptoms arise. 

Menorrhagia and Metrorrhagia. 

Definition. — The first of these two words is used to express an 
excessive menstruation ; the second, for a flow of blood not only at 
the menstrual time, but between menstruations. Neither condition 
is a disease ; both are symptoms of some well-defined pathological 
condition. The latter may be profuse or moderate. The patient 
who menstruates too freely is said to have menorrhagia, while one 
who sheds blood between the menstrual periods is said to have 
metrorrhagia. Women differ in the amount of the normal flow. 
What would be normal flow in one woman would be hemorrhage 
in another; accordingly, whatever the amount of flow a woman 
may have in health, during the first few years of her menstrual 
life, may be regarded as normal for her. In this particular each 
woman is a rule unto herself. 

Frequency. — Both of the above disorders are commonly met 
with. They may arise from many varying conditions. Any 
reliable attempt at the expression of the percentage of women 
who have menorrhagia or metrorrhagia cannot be made. 

Causes. — The numerous lesions causing too great a discharge 



94 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

of blood from the uterus demand most careful inquiry for their 
rational treatment. Each case of hemorrhage should be investi- 
gated independently for its cause. Indeed, all successful treatment 
will depend upon the finding of the cause. Frequently the same 
cause produces the two conditions. When the cause is an aggra- 
vated one it may occasion the continuous discharge of blood — me- 
trorrhagia ; during its process of disappearance, under treatment, 
it will be found that the metrorrhagia may be converted into 
menorrhagia, and that, in turn, may give way to the normal men- 
struation when the cause is entirely removed. It will thus be seen 
that it is a particularly difficult matter to differentiate between 
the causes of menorrhagia and metrorrhagia. 

All causes of uterine hemorrhage may be classed under two 
heads, general and local. 

The general causes involve general conditions, and are the fol- 
lowing : purpura, plumbism, severe icterus, scorbutus, Bright's 
disease, the spanemia of obesity, phosphorus-poisoning, malarial 
poisoning, the early stages of tubercular invasion, cardiac disease, 
and oftentimes, plethora. Hemorrhage may occur in the progress 
of an acute fever. In the majority of the above-named general 
causes, the plasticity of the blood is so diminished that clot-forma- 
tion is seriously impaired, and for this reason the loss of blood 
continues indefinitely. Such patients very often have periods of 
amenorrhea of indefinite duration, alternating with hemorrhages. 

The local causes may be reflex or direct. In the former cate- 
gory actual disease may exist or be absent. Among these cases may 
be classed the hemorrhages incident to puberty and the menopause, 
to the first intercourse, to lactation, and to any powerful emotion. 
The direct causes of all menorrhagias and metrorrhagias are the 
ones that demand our attention in the vast majority of all hemor- 
rhages. They include nearly every disease of the uterus and its 
appendages, as metritis, endometritis, subinvolution, granular cer- 
vix, retained secundines, retro-displacements of the uterus, fibroids, 
cancer, polypi, pressure outside of the endometrium, as from fibroid 
tumors and fecal accumulations, ovarian tumors, chronic ovaritis, 
chronic salpingitis, and acute pelvic inflammation. 

Attention is called to another form of hemorrhage from the 
uterus, occasionally seen, where pregnant women shed blood from 
the second to the sixth month without miscarrying, and apparently 
without endangering the life of the child. Speculum examination 






MENSTRUATION AND ITS ANOMALIES. 95 

carefully made fails to reveal the cause. The gestation is not neces- 
sarily interrupted, especially under conservative treatment, if pro- 
longed rest and quietude and careful abstinence from too active 
curative measures be observed. Women who have an habitual flow 
at what would be the menstrual period if they were not pregnant 
are not included in this class. The hemorrhage comes on at any 
time, and persists indefinitely, from a day to weeks, without inter- 
ruption, apparently uninfluenced by anything that can be done. 

Pathology. — From the conditions enumerated above it will be 
seen that whatever lesion induces too free a flow of blood to the 
uterus may become the cause of hemorrhage. Any one of these 
disorders existing alone may produce the flow ; with several coex- 
isting conditions the flow is still more certain to apj>ear. Occasion- 
ally violent hemorrhage will be witnessed from the uterus, when a 
careful examination will fail to determine the cause. 

Prognosis. — If the cause can be found and removed, the prog- 
nosis is good. If the cause cannot be found, the treatment must be 
symptomatic and the prognosis uncertain. If the cause can be 
ascertained, but cannot be removed, its natural history will deter- 
mine the prognosis. 

Many conditions result from these hemorrhages. We thus have 
general anemia, sterility, extreme emaciation, neurasthenia, wreck- 
ing of the health, and occasionally, death. 

Treatment. — The treatment of uterine hemorrhage is deter- 
mined by the cause. It is not always possible to determine the 
cause; in which 'case it is necessary to treat the hemorrhage em- 
pirically. The treatment of cases when the causes are known will 
be taken up in their order. 

When the causes are general, general treatment is required with- 
out interruption between the hemorrhages. For the treatment of 
these general causes the reader is referred to a work on general 
practice ; therefore no attempt will be made to direct their man- 
agement. 

When a well-defined local cause is discovered, its treatment 
should be outlined according to the directions given for treatment 
in the appropriate article elsewhere in this volume. Thus the 
treatment of metritis, subinvolution, cancer, chronic salpingitis, 
retained secundines, and fungosities of the endometrium will be 
found fully described under their appropriate headings. 

For the emergency of hemorrhage the number of remedies rec- 



96 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

omraended in the past is very large. First of all, the patient 
should be put to bed, and compelled to remain in the horizontal 
position, with the hips and lower extremities elevated. The more 
severe the hemorrhage the more imperative is this measure. It 
will oftentimes be found that a hemorrhage nearly stopped will 
be brought back in all its fury upon the patient arising from 
the bed to answer, for instance, the calls of nature. Cold applied 
to the lumbar and sacral regions contributes to diminish and check 
hemorrhages. In very severe cases of uterine hemorrhage, cording 
the arms and legs close to the body will be found of service : by 
this means large volumes of blood will be kept in the extremities 
for a sufficient length of time to permit clotting of the blood in 
the openings of the blood-vessels within the uterus. 

Of remedies used internally, the following may be mentioned : 
ergot, in twenty-drop doses, frequently repeated by the stomach, or 
in drachm- or two-drachm doses, with a drachm of deodorized tinc- 
ture of opium by the rectum; ergotin given in pill form, or canna- 
bis indica given to the point of producing mild hallucinations. 

Various vegetable astringents containing tannic and gallic acids 
as their base, as catechu, kino, and hematoxylon, have been recom- 
mended. 

The mineral astringents like alum, iron, and lead have also been 
used. 

In the moderate, persistent, erratic hemorrhages occasionally 
observed in parturient patients, digitalis is perhaps the best remedy 
that can be suggested. It operates by increasing the arterial ten- 
sion, thus diminishing the amount of blood going to the part suffer- 
ing the hemorrhage. Ergot in such cases is to be avoided for fear 
of interrupting the pregnancy. Hydrastis canadensis, quinine, 
hamamelis, strychnine, and especially atropia, are remedies that 
have been used to control hemorrhage in the non-pregnant uterus. 
Atropia is administered in doses of tfo of a grain three times daily 
for several days, or in smaller doses if the patient be very susceptible 
to the drug. These drugs are all alleged to exercise an influence 
upon the uterine muscles. Oil of erigeron and oil of cinnamon are 
at times effective where other remedies fail. 

Mineral acids have been recommended. The dilute sulphuric 
acid is (he safest and best. 

Treatment between Periods. — Women anemic from hemorrhage 
must he treated with tonics, protected from fatigue, and placed in the 



MENSTRUATION AND ITS ANOMALIES. 97 

best general hygienic conditions regarding rest, fresh air, and sleep. 
Due attention should be paid to the secretions and excretions. 
The marital relations are to be avoided. 

In very severe cases of hemorrhage, where the action of medicines 
cannot be awaited, immediate resort to mechanical measures is 
imperative. Rapid dilatation of the cervix and tamponing the 
uterine cavity with iodoform gauze are usually efficient in these cases. 
Occasionally, in especially spanemic patients, an oozing hemorrhage 
will continue through the iodoform -gauze tampon — a thing that is 
not likely to occur frequently, but when it does is an indication of 
too loose packing. 

Hot vaginal injections oftentimes control hemorrhage. They 
should be exceedingly hot and their use protracted. The effect of 
the heat is to produce a stimulation of the vaso-motor constrictor nerve, 
thus narrowing the blood-vessels contributing to the hemorrhage. 

It has been recommended, in cases of profuse menorrhagia occur- 
ring in slender, anemic women, to resort to tamponing the vagina 
at each menstrual period for several consecutive months — a pro- 
ceeding which does not stop the menstrual flow entirely, but which 
seems to do away with the excessive loss of blood. Should the 
amount of blood still be excessive and exhausting in spite of the 
vaginal tamponing, no hesitation need be entertained in resorting 
to uterine tamponade. Under this treatment women frequently 
regain their color, strength, and flesh. 

In cases of hemorrhage from lacerated cervix or cancer in the cer- 
vix uteri, the use of the persulphate of iron, with iodoform or boracic 
acid, is an excellent treatment. Where these fail vaginal tampons 
may be relied upon. 

Dysmexoeehea. 
Definition. — Dysmenorrhea means painful menstruation. Nor- 
mal menstruation is painless. The mild degree of discomfort and 
uneasiness experienced by many women is not included in this dis- 
order. Many women suffer pain during menstruation upon moving 
around, but are free from it while lying down. Women experienc- 
ing mild suffering only can scarcely be included under the head of 
dvsmenorrheic patients. 

* Desceiptiox.— The different manifestations of pain in dysmen- 
orrhea are very numerous. Some women experience pain until the 
flow is fully established, when all suffering ceases. Others have the 

7 






98 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

prodromic suffering, which extends through to the second day of 
the flow. Others have the prodromic pain and that of the first 
day or two, to be followed by complete relief for a time, when it 
will again reappear during, for example, the last day of the flow. 
With some the pain occurs suddenly with the flow, extends through 
the whole period, and gradually disappears as the flow ceases. 
Again, other women have painful menstruation every second month, 
having no pain at the alternate period. 

The seat of the pain varies in different women. In the vast 
majority of cases, the pain occurs in the hypogastric region ; in other 
cases it invades both the hypogastric and iliac regions. In still 
other cases it is circum-pelvic, starting from the lumbo-sacral region. 
Still other women have the pain located in one iliac region only. 
In severe cases it extends down one or both legs or up to the waist, 
or even to the axilla. 

In the vast majority of cases of dysmenorrhea the pain is not 
severe enough to demand the attention of the physician, quietude 
and domestic remedies sufficing to relieve the suffering. Some 
cases are so severe as to demand medical interference. In the 
severest cases the general health is undermined, the nervous 
system yielding the most urgent manifestations, such as hysteria 
gravior, mania, and even epilepsy. One case came under the wri- 
ter's observation many years ago, where it was necessary to perform 
artificial respiration for several hours during the flow. Some cases 
are so intractable as to defy remedial measures, necessitating the 
operation of oophorectomy. 

A certain phenomenon occasionally observed has been denomi- 
nated intermenstrual dysmenorrhea. It is characterized by spas- 
modic pains in the iliac regions, occurring in the interval between 
the menstruations. It is only occasionally met with, is rebellious 
to treatment, and has been so severe as to demand the removal 
of the ovaries for its abolition. 

In one form of dysmenorrhea the pain is slight in the beginning, 
and progressively increases until it reaches a climax, suddenly 
terminating in a gush of blood from the vaginal orifice. It is fol- 
lowed by a period of comparative relief from pain, which, in a few 
minutes or an hour or two, is succeeded by another similar parox- 
ysm of suffering. This variety is seen in many cases of uterine 
flexions. Jt has been characterized, perhaps erroneously, as tubal 
colic. 



MENSTRUATION AND ITS ANOMALIES. 99 

Varieties and Pathology.— Writers have described many 
varieties of dysmenorrhea. While the tendency of this sort of 
teaching, unqualified, may be misleading, it is perhaps best to sub- 
divide the subject into varieties for convenience of description. 
Above all, it must be borne in mind that dysmenorrhea is always 
a symptom of some pathological condition which utterly precludes 
the possibility of routine treatment. Indeed, any attempt to treat 
all cases alike is the merest charlatanism. The names given to 
express the different varieties of dysmenorrhea imply the leading 
pathological conditions. It must be understood that one or two, 
or even three varieties of causes may be found in the same patient ; 
therefore it is possible for one patient to have one or more varieties 
of dysmenorrhea, just as any person may have one or two or three 
different kinds of headaches. It will be seen that the completest 
examination of each case is absolutely necessary in order to intelli- 
gently institute treatment. Like amenorrhea, menorrhagia, and 
metrorrhagia this condition is merely a symptom, not a disease. 
The following varieties have been described by authors : 1. Neu- 
ralgic ; 2. Congestive ; 3. Mechanical ; 4. Ovarian ; 5. Membranous. 

1. Neuralgic. — This variety may not be associated necessarily 
with any disease of the pelvic organs. It manifests itself chiefly 
in the class of patients of nervous or neuralgic temperament. 

Causes. — Any constitutional condition which tends to develop 
the neuralgic disposition, as anemia, chlorosis, gout, rheumatism, 
syphilis, malaria, and the like, will precipitate neuralgic dysmen- 
orrhea. This form of the complaint includes cases from the 
very lightest to the very gravest variety. 

2. Congestive. — During menstruation the pelvic organs are 
congested. When it is normal no pain exists. When there is a 
state of chronic inflammation, or distorting and deforming adhe- 
sions from pelvic inflammation, the normal congestion becomes an 
abnormal one, and pain results, constituting what is known as con- 
gestive or inflammatory dysmenorrhea. Even in conditions of 
chronic endometritis the menstrual congestion is sufficient to pro- 
duce this form of dysmenorrhea. The various forms of tumors, 
as fibroids and polypi, may also constitute a cause. 

This form of the malady is seen most frequently in women who 
have borne children or have aborted, and in women who began the 
menstrual life and maintained it for a given length of time without 



100 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

pain. It is the variety which is nearly always traceable to some 
disorder of which the patient will give the history. 

3. Mechanical. — In this class of cases there is some obstruc- 
tion to the ready outflow of the menstrual fluid. It can come from 
a great variety of conditions. It may occur from stenosis of the 
cervical canal, produced by any mechanical cause, as severe inflam- 
mation, pressure from tumors in the neck of the uterus, or from 
excessive use of caustics. It may arise from flexion or version 
of the uterus. It may spring from an intra-uterine polypus acting 
as a ball-valve at the internal os, or from a stricture of the vagina, 
or from an imperforate hymen. 

In this variety the commonest characteristic symptom is the 
paroxysmal pain accompanied by a gush of blood from the genital 
passage. However, the pain is by no means always paroxysmal. 

• 4. Ovarian. — In this class of cases a careful examination will 
almost always discover some enlargement or tenderness of the ova- 
ries, and reveal a condition which is called chronic ovaritis. As 
chronic ovaritis is never wholly free from some pelvic peritonitis, it 
is easy to understand how the congestion of the menstrual epoch will 
produce a great amount of pain both before and during the flow. 
By careful examination through the conjoined manipulation, one 
or both ovaries can be detected prolapsed somewhat, and perhaps 
nearer to the uterus than is normal. They are characterized by 
their increase in size and by their excessive tenderness. The Inac- 
cessibility of these organs to treatment indicates the extremely grave 
prognosis for such patients. 

5. Membranous. — Patients of this class shed, with the flow, a 
membrane which is the decidua menstrualis. This membrane, 
when whole, consists of a sac representing the cast of the triangular 
cavity of the body of the uterus with its three openings, of the Fal- 
lopian tubes and the os uteri. It may come away whole or in 
the shape of shreds and fibres. Microscopically, it is found to be 
what might be denominated hypertrophied decidua menstrualis. 
The blood-vessels are easily seen increased in size, capacity, and 
number; the interglandular substance is greatly increased; there 
is i great development in the utricular glands, whose mouths are 
visible even to the naked eye. Pregnancy is excluded by the 
entire absence of the chorionic villi. 

Tin' pathology of the dysmenorrheal membrane has received a vast 
amount of attention. Many varying theories have been advanced, 



MENSTRUATION AND ITS ANOMALIES. 



101 



maintained, and abandoned. The theory which is, perhaps, the 
most favored to-day, is that it is an exaggeration of a physiological 
process with a varying pathogeny. In other words, the membrane 
is regarded as an exaggerated decidua menstrualis of inflammatory 
origin. It would seem that the therapeutic proof of this theory 
affords the most convincing argument. Whatever cures the accom- 
panying endometritis in cases of membranous dysmenorrhea is cer- 
tainly, to-day, its most reliable and satisfactory treatment. 

Symptoms. — Pain is the one symptom characterizing every 
variety of dysmenorrhea. A few of its variations are so greatly 
pathognomonic that observation of them is sufficient for a correct 
diagnosis. 

In the neuralgic variety the undulatory character of the pain is 
always pathognomonic. In addition to this characteristic of the 




pain, a marked degree of hyperesthesia of the cutaneous surface 
of the lower abdomen will always be found present. The coexist- 
ence of neuralgia in other localities and the identification of Valleix's 
painful points will facilitate the diagnosis. The pain in this variety 
shows itself before the flow has been established, and disappears as 
soon as it comes on, or continues through to the end of the flow, 
coming and going with no apparent cause. It is in this form of 
dysmenorrhea that we find the largest number of incoercible cases. 
The pain may become so agonizing as to make the patient delirious ; 
its severity before, during, and after the flow may be so demoraliz- 
ing to the physical strength of the patient as to ruin her health 



102 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

entirely. More cases of destruction of the general health occur in 
this variety than in all the others combined. 

The symptoms of the congestive variety are observed chiefly in 
patients who have previously menstruated painlessly. The pain, 
coming on suddenly, is very severe in this class of cases, seems to 
be confined to the pelvis, and is accompanied by a diminution or 
cessation of the discharge. The constitutional symptoms are always 
marked : the pulse is increased in frequency, the temperature ele- 
vated, the skin hot and dry, and the eyes suffused. There is severe 
headache, occasional delirium, marked diminution in the renal secre- 
tions, and general restlessness. In this variety of the complaint the 
patient usually experiences pain upon walking, is easily fatigued, has 
leucorrhea and an irritable bladder, not only at the time of the flow, 
but during the intermenstrual periods. There is a marked contrast 
in this class of patients to the women suffering from neuralgic dys- 
menorrhea. The pelvic malady seems never to leave them between 
menstruations, whereas women who suffer from a purely neuralgic 
dysmenorrhea experience trouble chiefly at the time of menstrua- 
tion. The syndroma of this form of the disease can readily be 
perceived by bearing in mind the fact that the uterus possesses a 
pathological congestion, not only between the menstruations, but 
also throughout all the menstrual flow. 

The symptoms of the mechanical or obstructive form of dysmen- 
orrhea are peculiar and very characteristic. What has been styled 
uterine colic is the kind of pain most frequently encountered. After 
the menstruation has continued for several hours, and some blood 
has accumulated in the fundus uteri sufficiently to distend it, uterine 
contractions are set up which increase in intensity, until the accu- 
mulated blood is forced out of the uterus in a gush. Then the 
severe pain ceases for a time until the distention from re-accumula- 
tion occurs, which is followed by another series of uterine contrac- 
tions, terminating in the expulsion of the blood. The obstruction 
to the outflow of the blood may exist in the cervical canal, in the 
vagina, or the vulva. When the obstruction exists in the cervical 
canal, the uterine contractions will expel a small clot of blood, fol- 
lowed by a gush, affording complete relief from suffering for the 
time being. The symptoms are so marked that the diagnosis of 
this form can be made without any hesitancy, as a rule. The 
physician must be on his guard, however, not to be deceived by 
the accumulation of the menstrual fluid in the vagina, and its. 



MENSTRUATION AND ITS ANOMALIES. 103 

periodic expulsion in gushes, according as the patient assumes 
various positions, or the cul-de-sac becomes filled. 

The symptoms of ovarian dysmenorrhea are characterized by a 
period of prodromic suffering extending over several days. The pain 
is dull in character, confined to one side when originating from one 
ovary only, extends around the pelvis, over the nates, and down the 
thighs, and is peculiarly liable to be accompanied by an invasion 
of the general nervous system and depression of spirits. Painful 
and tender mammary symptoms often occur in this variety. Inter- 
menstrual dysmenorrhea is observed more frequently perhaps in 
this than in any other form of the complaint. Sometimes it occurs 
on the ninth, sometimes on the fifteenth, sometimes on the twelfth, 
and sometimes on the seventh day after cessation of the menstru- 
ation. Occasionally it is seen only after every second menstruation. 
A pelvic examination often reveals an enlarged, tender, and pro- 
lapsed condition of one or both ovaries. It must not, however, be 
supposed that in all cases of enlarged and tender or prolapsed ova- 
ries, ovarian dysmenorrhea will be found. Not every case of ovarian 
dysmenorrhea presents a detectable pathological condition of the 
ovaries. 

In membranous dysmenorrhea the pains usually begin with 
the flow. After being ushered in they increase as the flow pro- 
gresses, until the type of veritable labor-pains is reached. Dur- 
ing the repetitions of these contractions the os uteri dilates, and 
the membrane is shed in its entirety or in shreds from the vaginal 
orifice. Usually the pain ceases at this time ; then ensues a mode- 
rate menorrhagia, which soon disappears. This is followed by a 
purulent or sero-purulent discharge, continuing indefinitely from 
a few days up to the ensuing menstruation. Sterility is the rule in 
this class of patients, and the women are of an extremely neurotic 
tendency. The one characteristic of membranous dysmenorrhea 
is the membrane. 

Diagnosis. — The diagnosis of neuralgic dysmenorrhea involves 
the consideration of the entire nervous system. The neuralgic tem- 
perament or diathesis is unmistakably present. Valleix's tender 
points are easily determined. The undulating characteristic of the 
pain is always present. The pain is not like labor-pains, as in 
membranous dysmenorrhea, and the suffering is not continuous, as 
it is in the congestive variety. There are no constitutional dis- 
turbances between the menstruations; there are no signs of endo- 



104 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

metritis, of ovarian or perimetritic disturbances. The pain is 
habitual, and not paroxysmal. Between the menstruations there 
are no pains, and no leucorrhea, and the patient appears to be in 
ordinary good health. In the severer forms invasion of the gen- 
eral health often occurs, presenting, in degrees of varying intensity, 
neurasthenia, hysteria gravior, delirium, mania, or epilepsy. 

In the congestive variety without a conspicuous endometritis or 
general metritis the attack of pain is sudden. There is an absence 
of constitutional disturbances, and the pain ceases after the flow 
stops. In the congestive variety with a marked uterine inflamma- 
tion there is always constitutional disturbance, such as rise of pulse 
and increase of temperature, and the patient is never wholly free 
from pelvic suffering between the menstruations. This characteris- 
tic is in marked contrast to the dysmenorrhea from neuralgic origin. 

The diagnosis of the mechanical or obstructive form of dysmen- 
orrhea is made chiefly from the expulsive and paroxysmal occur- 
rence of the pains. A physical examination is necessary to complete 
the diagnosis and to discover what is the underlying pelvic condi- 
tion present. Conjoined manipulation will easily disclose the pres- 
ence of anteflexion. Tumors in the cervix may easily be discovered 
by the finger. Deflections of the uterine canal can be demonstrated 
by the use of the sound. Should the obstruction exist in the vagina, 
it will soon become apparent upon a digital examination. Occa- 
sionally it will be found that the only obstruction existing in the 
uterine canal is an unusual reduplication of the lining membrane 
of the uterus at the internal os, and a spasmodic constriction of the 
muscular fibres at the opening. 

Prognosis. — Dysmenorrhea has usually a favorable prognosis. 
In the vast majority of cases of the neuralgic variety the prognosis 
is entirely favorable. Occasionally it will be found that an inco- 
ercible case of neuralgic dysmenorrhea will be encountered, wherein 
all medical treatment will prove utterly unavailing. In such cases 
there seems, unfortunately, to be but one cure, and that is to induce 
artificially the change of life by the removal of the ovaries. 
Where there is one case demanding resort to this operation, there 
arc many thousands that need nothing of the kind. 

Of the congestive variety, the prognosis is almost always favor- 
able, the cure of the patient depending upon the success of the 
treatment instituted for the inflammatory condition present. 

The prognosis of casts of mechanical and obstructive dysmen- 



MENSTRUATION AND ITS ANOMALIES. 105 

orrhea depends wholly upon the success of the treatment insti- 
tuted to abolish the obstruction. 

In ovarian dysmenorrhea where organic degeneration of the 
ovaries exists, the prognosis is favorable only in case of removal 
of these organs. Where such degeneration is absent, the treatment 
of ovarian congestion or of ovaritis, when successful, will cure the 
dysmenorrhea. 

Membranous dysmenorrhea presents a not very favorable prog- 
nosis in the greatest number of cases. Occasionally patients will 
be seen whose general health is so degenerated that all treatment of 
this form of the malady proves utterly fruitless. 

Treatment. — The variety of the dysmenorrhea always decides 
the treatment. No case is intelligently treated wherein an attempt 
at satisfactory diagnosis is not made. In general, it may be said 
that the routine treatment of any form of dysmenorrhea by means 
of the preparations of opium and diffusible stimuli, is to be con- 
demned. There is no question that opiophagists and drunkards 
have been made by this line of inconsiderate treatment, This 
assertion may be disputed, and is disputed, by some physicians, 
but their observations must be considered too limited to be relia- 
ble. This general statement may be made concerning the use of 
these two remedies in dysmenorrhea : He who is compelled to 
resort frequently to opium and stimulants, must be considered 
devoid in diagnostic ability, and consequently ought not to be 
•entrusted with the management of such cases. 

Neuralgic Variety. — The treatment of this form may be subdi- 
vided into general and specific treatment. In the beginning of the 
treatment the physician must carefully ascertain the general state 
•of the patient. If she be of the rheumatic, gouty, or syphilitic 
•diathesis, this must be met by the usual remedies ; in other words, 
the physician must treat assiduously the systemic condition which 
seems to predispose to the development of this neuralgia. The daily 
free administration of laxatives and diuretics is advisable. Should 
a local cause for the constipation be found in the anus or rectum, 
it should be removed by surgery or otherwise. Free daily evacua- 
tions of the bowels are indispensable to the restoration of the 
physiological balance of these patients. Constipation may lead to 
fecal anemia. In women thus affected neuralgic dysmenorrhea is 
•extremely common. Rheumatism should be treated with colchi- 
«um, guaiac, the salicylates, and the preparations of potash. Gout 



106 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

requires the administration of minute doses of calomel, as one- 
twentieth of a grain three times a day, and with the citrate of 
potash or lithia. Syphilis calls for mercury and iodides. An anemia 
demands tonics. An underlying fermentative dyspepsia, which may 
be one source of degenerated general health, requires gastric lava- 
tions, creasote, glycozone, and other antiseptic remedies. 

When the first consideration of the treatment of the patient — 
namely, constitutional treatment — has been provided for, then 
attention should be turned to remedies specially addressed to 
the relief of the suffering. In this class of patients purely 
antineuralgic remedies oftentimes yield most brilliant results. 
Phenacetin and antipyrine will relieve a large number of these 
cases. Many remedies have been recommended to be given a 
week before the flow comes on, to prevent the pain arising in 
neuralgic dysmenorrhea. Apiol has been given as a preven- 
tive of these pains, five minims in a capsule three times a day 
for one week before the flow appears. Five drops of the tinc- 
ture of pulsatilla, in water, three times a day, are similarly recom- 
mended. If given for a week beforehand, guaiac or the sodium 
salicylate will oftentimes prevent an attack of neuralgic dysmenor- 
rhea in women of the rheumatic diathesis. For the treatment of 
the pain, when it has occurred, auxiliary measures should not be 
neglected, such as rest and the application of warmth to the skin. 
The best results are perhaps yielded by ten or twenty grains of anti- 
pyrine or phenacetin, repeated hourly, until two or three doses, if 
necessary, are given. The best effect from these remedies is 
obtained when the patient lies with closed eyes in a quiet, darkened 
room for half an hour after taking them. Usually one dose of 
phenacetin is sufficient ; sometimes a second or third dose is neces- 
sary. The well-known depressant cardiac action of the remedy 
can best be anticipated, if necessary, by the administration of twenty 
or thirty drops of the tincture of digitalis. This remedy, digitalis, 
is occasionally necessary. Nitro-glycerin and amyl nitrate, given 
until flushing arises, oftentimes produce excellent results. Six- 
grain doses of the oxalate of cerium every hour have been recom- 
mended. The tincture of cannabis indica, in twenty-five -drop 
doses every three hours, given even to the production of halluci- 
nations, is oftentimes effective. Chloral hydrate in ten-grain doses, 
repeated hourly until three or four doses have been given, will 
often relieve pain. Where the spasmodic element appears to exist, 



MENSTRUATION AND ITS ANOMALTES. 107 

as will be indicated by a great diminution of the flow, the solanacese 
will be extremely useful. Thus belladonna, hyoscyamus, or stra- 
monium given to the production of mydriasis is often very effective. 

A general hot bath, from twenty to thirty minutes, frequently 
produces great relief. 

Occasionally -the paroxysms of pain are so terrible that we are 
justified in using hypodermic injections of morphine and atropia, 
but they should always be the last resort. 

The treatment of the patient, in cases so severe, should be most 
assiduous and careful, to ascertain if it be not possible to avoid the 
further use of opium. Very rarely a case of incoercible dysmen- 
orrhea, mentioned above, will resist the treatment — even that of 
hypodermic injections — when the removal of the ovaries for the 
artificial induction of the menopause will be imperatively demanded. 

The Congestive Variety. — Herein the treatment must be directed 
by the diagnosis of the cause of the congestion. If it be due to the 
plethora of a retro-displacement of the uterus, the organ must be 
properly sustained. A wool tampon soaked in glycerin, adjusted 
with the patient in the genu-pectoral position, will suffice to thrust 
the fundus forward into its proper place, where the organ can empty 
itself satisfactorily. If upon examination the uterus is found to be 
decidedly congested, as shown by the distended condition of the 
blood-vessels or by the purple appearance of the cervix, leeches 
or scarification will suffice to relieve. Should the attack be precipi- 
tated by catching cold, the use of the saline cathartics, a diuretic, 
and a diaphoretic will be indicated. When the congestion arises 
from the pressure of an extraneous growth, either within or with- 
out the uterus, the case will be cured only upon the removal of 
the cause. 

Mechanical or Obstructive. — The best-recognized treatment of 
ordinary cases of cervical constriction, whether acquired or con- 
genital, is forcible dilatation. If this be decided upon, the patient 
should be thoroughly anesthetized, placed in the lithotomy posi- 
tion, the cervix exposed by the use of retractors, seized with 
the vulsellum forceps and drawn down toward the vaginal orifice. 
The direction of the uterine canal should be determined by the use 
of the uterine sound. If the cervical orifice be too small to admit 
the blades of the Goodell dilator, a narrow dressing forceps can 
first be passed within the internal os, and its blades sufficiently sep- 
arated to enable the Goodell dilator to be subsequently introduced. 



108 AN A3IEBICAN TEXT- BO OK OF GYNECOLOGY. 

With the set-screw this dilator can be opened to the extent of an 
inch or an inch and a half, five or ten minutes being consumed in 
its accomplishment. If any evidences of endometritis exist, the 
endometrium should be mildly curetted. Should granulations be 
brought out, then the curetting must be very thorough and the 
entire endometrium gone over systematically. It. is not necessary 
to wash out the uterine cavity with an antiseptic liquid, because 
it can be thoroughly emptied with the curette. The irrigation can, 
however, do no harm, and should be practised. A narrow piece 
of iodoform gauze should then be packed into the uterine cavity 
until it is filled, and allowed to remain fbr a space of two days. 
Subsequent pain of uterine contractions can be held in check by 
the use of moderate doses of opium in some form. This method 
of relieving mechanical dysmenorrhea is remarkably successful in 
the majority of cases, but not in all. Direct electrolytic treat- 
ment of the cervical canal, in a manner similar to that used in the 
treatment of the male urethra, has been urged as absolutely cer- 
tain, in preference to the dilatation measures. 

Sponge, laminaria, and tupelo tents have been used a great deal 
in the past, Progressive gynecologists rarely resort to their use at 
present, because of the possibility of sepsis following. Forcible 
dilatation has been found much preferable. 

When the constriction does not exist within the cervical canal, it 
is usually the result of some severe inflammation, as from the use of 
caustics or from some cervical laceration occurring in labor. In 
such cases it is necessary to lay open the internal os by cutting 
with a knife or scissors. In order to keep the os patulous the use 
of the intra-cervical stem pessary for two or three months generally 
suffices. When the constriction arises from flexion, the favorite 
method of treatment is the use of an intra-uterine stem pessary, 
constantly worn for a year or longer. In married women the use 
of this stem pessary is often followed by conception. If the gesta- 
tion go on to term and end in a normal labor, the involution 
of the uterus is usually followed by a return of the flexion. In 
this manner it is shown that uterine flexions are oftentimes in real- 
ity incurable. To meet this condition the operation for the forma- 
tion of an artificial os uteri upon the convex side of the cervix has 
been devised. It consists of the division of the cervix up to the 
point of the flexion and the turning in of the mucous membrane 
to form an artificial os uteri. This surgical procedure is of such 



MENSTRUATION AND ITS ANOMALIES. 109 

recent introduction that the verdict concerning its merits is still 
held sub judice. 

When the obstruction arises from an intra-uterine polypus, its 
removal constitutes the only relief. 

Obstruction residing in the vagina must be treated by dilatation 
either by large bougies, tents, or incision. 

Should the obstruction arise from syphilis, constitutional treat- 
ment must be conjoined. 

Where the obstruction is produced by an imperforate hymen, 
the only relief consists in its division. 

If a fibroid tumor constitutes the cause of obstruction, one of 
the methods for disposing of this condition must be employed. 

The Ovarian Variety. — The treatment of this class of cases is 
perhaps the least satisfactory of all classes of dysmenorrhea. Should 
pregnancy occur, the nine months of rest secured to the ovaries may 
become of signal service. However, in such cases sterility is the 
rule. It is especially in this class of cases that opium and alcohol 
should be avoided. Remedies to soothe the local irritation and to 
decongest the pelvic organs are to be resorted to. The use of the 
wool-glycerin tampon accomplishes this object most effectually of 
all known means. During the flow complete rest in bed and 
low diet, and the free use of bromides for a few days before the 
flow begins, will make many of these patients quite comfortable. 
Hyoscyamus, cannabis indica, exalgine, and stramonium often- 
times give satisfactory results. Internal medication in this vari- 
ety of cases is more often unsatisfactory than otherwise. 

Where unmistakable evidences of organic ovarian disease exist, 
the operation for the removal of the ovaries is demanded. Even 
the removal of the ovaries will at times fail to give the expected 
relief. Whatever is done to relieve the pain of this variety, short 
of oophorectomy, must, as a rule, be repeated monthly. 

Membranous Variety. — The uncertainty of the pathology of this 
disorder has led to the most astonishing variety of treatments. 
Indeed, it can be said that the same uncertainty of treatment exists 
to-day that existed a quarter of a century ago. The largest num- 
ber of successful treatments of cases has followed the repeated dilat- 
ing and curetting of the uterus. Many times these treatments fail ; 
many more times they are successful. Internal treatment for its 
cure is wellnigh abandoned. A few years ago large doses of iodide 
of potassium were used; this is now abandoned. All varieties of 



110 AN AMERICAN TEX1-BOOK OF GYNECOLOGY. 

constitutional treatment have been tried and abandoned. The 
consensus of opinion is now centred chiefly upon the treatment 
by dilatation and curettement, in conjunction with the applica- 
tion of chloride of zinc or carbolic acid, for the purpose of destroy- 
ing the portion of membrane left behind by the curette. 



STERILITY. 



Synonyms. — Barrenness ; Infertility ; Lat., Sterilitas matrimonii ; 
Fr., Sterilite ; Ger., Unfrucbtbarkeit. 

Sterility in the female implies an inability to bring forth a liv- 
ing child. It involves two points for consideration : first, her 
inability to conceive at all ; and, second, her inability to complete 
successfully the period of gestation. Many women never conceive 
at all. Many other women conceive, but are unable to complete 
the period of gestation. 

Women who never conceive are said to be absolutely sterile. 
Women who have borne one or two children and do not conceive 
thereafter are said to be relatively sterile. While a woman is nurs- 
ing her new-born child, as a rule, menstruation does not appear. 
During this period sterility generally exists, although women occa- 
sionally conceive even under these circumstances. This condition 
may be called physiological sterility. Under this heading is in- 
cluded that form of sterility which exists and is permanent after 
the woman has passed the change of life. 

Etiology. — Several organs are involved in the process of genesis 
in the female. The essential element of this process is the ovum, 
which is supplied by the ovary. The ovum is conveyed from the 
ovary through the Fallopian tube to the uterus, where it meets the 
spermatozoon, and genesis follows, provided it has not been impreg- 
nated at some point between the ovary and the uterus. The semen 
reaches the uterus through the vagina. Consequently, the question 
of sterility involves the investigation of the condition of, first, the 
ovaries ; second, the oviducts ; third, the uterus ; and, fourth, the 
vagina. In addition, upon the general condition of the patient 
alone non-conception often depends. Under this head may be 
classed the extreme gouty vice, the syphilitic taint, anemia, great 
obesity, chronic alcoholism, and spasmodic dysmenorrhea. 

The Ovaries. — 1. The investigation of the ovaries in sterility 
includes inquiry into the possibility of the absence, or of the im- 



112 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

perfect development, of these organs — conditions rarely met with, 
excepting when the other sexual organs are anomalous. 

2. Inflammation of the ovaries, chronic or acute, may result in 
such adhesions of the organs that the ovum is totally prevented 
from entering the oviducts. It may lead to arrest of function, so 
that the ovum can no longer be matured. The ovary may become 
so imbedded in inflammatory deposit that extrusion of the ovum 
from its capsule is no longer possible. 

3. Structural degenerations of the ovary may exist — e.g. cystic,, 
carcinomatous, sarcomatous, and interstitial changes — and are gene- 
rally attended with sterility. 

4. Displacement of the ovary, often attended with chronic inflam- 
mation, may place it beyond the reach of the fimbriated extremity 
of the Fallopian tube so completely that the ovum cannot be trans- 
mitted to the uterus. 

The Fallopian Tubes. — 1. Absence or defective development 
of the oviducts is usually associated with other abnormalities of 
the sexual system, and causes hopeless sterility. 

2. Inflammation of the oviducts is a cause of sterility. It may 
affect the serous coat, resulting in such fixation of the tubes as to 
prevent the morsus diaboli from coming in contact with the ovary, 
or in the formation of constricting bands that occlude the calibre 
of the tube. It may attack the mucous lining of the canal, and 
result in the production of secretions which are destructive to the 
spermatozoa or the ova, or it may result in permanent occlusion of 
the opening of the tube, whence may follow collections of blood, 
pus, or serum. In either case the ovum is prevented from de- 
scending to the uterus, and sterility follows. Of most importance 
is the destruction of the epithelia lining the mucous layer of the 
tube, with their cilia, resulting in the inability of the ovum to pass 
along the oviduct, either before it has met the spermatozoon or 
afterward, in the former case the result being sterility; in the 
latter, ectopic gestation. 

3. Degeneration of the tubal structures produces a hopeless 
occlusion of the canal, and thus causes sterility. 

The Uterus. — Defective development of the uterus assumes vari- 
ous forms, such as its total absence, its under-size, or its abnormal 
lateral growth into either a unicornus or a bicornus uterus. Conoi- 
dal cervix, with the commonly attendant stenosis of the os, may be 
classed as one of the variations of defective development. The last- 



STERILITY. 113 

mentioned condition constitutes one of the most frequently remov- 
able causes of sterility. 

Degenerations. — 1. Myomata often cause infecundity, but they are 
not always a barrier to conception. The coexistence of this degen- 
eration and of pregnancy constitutes one of the most serious con- 
ditions encountered by the obstetrician. 

2. Sarcomata seem always to prevent pregnancy. 

3. Carcinomata, if extensive enough, cause sterility. In their 
early stage conception is often possible, and is now and then 
encountered. 

Abnormalities of Involution. — An excessive involution (hyper- 
involution) or a deficient involution (subinvolution) often consti- 
tutes a barrier to conception. The writer recently saw a healthy 
patient, aged twenty-seven, who bore a child at twenty-one years 
of age, and had not menstruated since that event. The uterus 
measured but one and one-fourth inches in depth. The organ may 
still further be decreased in size, even to a quarter of an inch. 

Subinvolution of the uterus is often accompanied with an inflam- 
matory state, completely preventing the occurrence of pregnancy. 

Inflammation of the uterus or the circumjacent tissues is a very 
common cause of sterility. The morbid process, according to its 
seat, may be endocervicitis, endometritis, metritis, or pelvic inflam- 
mation. Often two or more of these conditions coexist and render 
the cure very tedious or impossible. Endometritis may be accompa- 
nied by abnormal secretions destructive to the spermatozoa ; there 
may be a dilated uterine cavity ; the lining membrane of the uterus 
may be made so unhealthy that it becomes impossible for a fertil- 
ized ovum to secure a lodgment thereon ; or the inflammation may 
cause more or less occlusion of the uterine orifice. 

Displacements. — Malpositions of the uterus include prolapse, 
flexions (retroflexion, anteflexion), and versions (anteversion, 
retroversion, and latero version). 

Anteversion and anteflexion exist most frequently in nulliparae. 
Retroversion and retroflexion exist most frequently in those who 
have borne children. Lateral displacements are present when 
an inflammation has existed in either broad ligament, resulting in 
its shortening, or when some foreign growth or an inflammatory 
deposit exists on the side of the pelvis, opposite to the displace- 
ment, crowding the uterus away from its normal position. 

The Vagina. — This organ may be so injured, or may become the 



114 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

seat of discharges so fatal to the semen, that it becomes a source of 

sterility. 

Malformations. — The vagina may be absent congenitally. Its 

occlusion is very rare, but exists, both as a congenital and an acquired 

condition. A severe vaginitis has been the cause of an almost total 

occlusion, by the agglutination of the vaginal walls. The hymen is 

sometimes so hypertrophied that it becomes a barrier to copulation. 

Unnatural shortness of the vagina renders it incapable of retaining 

the semen for a suitable length of time. 

Inflammation. — Vaginitis nearly always produces discharges fatal 

to the semen. It is occasionally productive of that condition of 

spasm called vaginismus, but this is more frequently caused by 

other conditions. 

Injuries. — Extensive perineal lacerations often become causes 

of sterility by shortening and straightening the vagina. Fistulas 

may also prevent conception. 

Degenerations. — Elephantiasis labiorum prevents coitus, and 

thus becomes a barrier to insemination. Extensive urethral carun- 
cle often interferes with successful intercourse. 

General State of the Patient's Health. — An indefinable 
something in the patient's general condition is oftentimes the appar- 
ent cause of sterility. The proof of this statement consists in the fact 
that women sterile when in poor health often conceive when their 
general condition has been improved by remedies, by change of 
climate, or by travel. Some women are sterile because of the pres- 
ence of discharges from the genital tract which have their origin in 
a systemic taint. The lithemic state, for example, may give rise 
to discharges, which cease when an antilithic course of treatment 
has been followed, and conception thereafter may follow. Many 
cases of sterility of this form have been wholly removed by a 
course of treatment at suitable mineral springs. 

Under this head may also be mentioned that variety of steril- 
iiy which is dependent upon some obscure incompatibility of the 
parties, illustrations of which every physician of experience has 
encountered. A woman, sterile in many years of married life, 
who has been for this reason abandoned by her husband, eventu- 
ally secures a divorce, is married to a second husband, and bears 
a number of children. The old illustrations of Augustus and 
Livia, and of Napoleon and Josephine are quoted by writers on 
sterility. 



STERILITY. 115 

It is well never to lose sight of the fact that the cause of ster- 
ility may be resident in the male, and when no cause can be found 
resident in the wife, a critical examination of the husband should 
be made. Not infrequently the physician will be rewarded by the 
discovery of the defect. It is possible that, in a certain proportion 
of the cases, when the woman has conceived by a second marriage 
the defect existed in the first husband. 

Diagnosis. — It is not always the case that only one of the foregoing 
obstacles to conception is present. Very often two or more of them 
coexist. When the causes of sterility are manifold in the same 
patient, it is obvious that the skill of the gynecologist will often be 
taxed in recognizing and removing them. A complete diagnosis 
can be arrived at only by an exhaustive examination. It is always 
a safe plan for the physician to endeavor to find all of the possible 
causes of sterility in his patient. 

Frequently, after every discoverable obstacle to conception has 
been corrected, sterility will still exist. 

Prognosis. — In no condition is the prognosis more uncertain. 
In a general way it may be stated that imperfect development or 
marked malformations constitute an absolute bar to conception. 

In the same manner, it may be stated that removable obstacles 
to conception, as inflammations, flexions, versions, stenosis, some 
vaginal occlusion, or fistula?, may be treated with a fair prospect of 
fruitful results. The apparently complete removal of these obsta- 
cles, however, only too often fails to render the woman fruitful. 

Treatment. — A successful treatment of sterility in the female is 
secured by removal of all the obstacles to conception. Such treat- 
ment does not include that of sterility in the male, although many 
gynecologists investigate the male first, since about one case in ten 
of infecundity in marriages has its origin in the male. With this 
branch of the subject, however, the present article has nothing 
to do. 

After the physician has discovered as many obstacles to concep- 
tion as he can find, he must set about removing them. Insufficient 
treatment nearly always results in failure. In no department of 
gynecology is more persistence in treatment demanded. 

Urethral caruncles, vulvar vegetations, and other sensitive ex- 
crescences must be removed or destroyed. 

Vaginal stenosis or contraction must be stretched, and the canal 
kept patulous. 



116 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

Cervical stenosis must be overcome by sea-tangle or tupelo tents 
or by stretching with dilators. Division of the cervix by the 
hysterotome has been successfully practiced in the past, but is at 
present falling into disuse, forcible dilatation being preferred. 

Uterine deviations must be corrected. Versions can often be 
rectified by suitable pessaries. It has been suggested that ante- 
version may be corrected by allowing the bladder to become dis- 
tended with urine, thus pushing the fundus uteri backward and 
throwing the cervix sufficiently forward, to place the os in a direct 
line with the seminal ejection ; the entrance of the semen into the 
cervical canal is thus facilitated. Similarly, retroversion, it is 
alleged, may be temporarily corrected by allowing the rectum to 
become distended with feces, whereby the fundus uteri may be 
crowded forward. It would seem most probable that both these 
procedures would defeat the desired object. Either one or the other 
would tend to destroy the natural S-shape of the vagina, producing, 
in a milder degree, the same condition of straightening of the canal 
as is produced by laceration of the pelvic floor. Especially in the 
case of constipation the result would be a tendency to non-retention 
of the semen in the vagina. The theory of sterility being due to 
a backward or downward position of the cervix has long been ex- 
ploded. 

Flexions demand the use of the intra-uterine stem pessary. 

Hyperinvolution may be treated with the galvanic intra-uterine 
stem pessary. Similarly, attempts may be made to stimulate the 
growth of an imperfectly developed uterus. 

Inflammations must be treated secundum artem. Various anti- 
phlogistic methods of treatment are in vogue. Cauterizing applica- 
tions, hot-water douches, glycerin tampons, etc., each has its ad- 
herents. 

Morbid growths on the endometrium must be removed or de- 
stroyed. 

Quite exceptionally, the method of introducing semen into the 
uterus by means of a syringe and tube has been used, it is alleged, 
successfully. 

In the treatment of all cases of sterility the physician must never 
ignore the general condition of the patient. Systemic vices must 
be eradicated as far as possible. Many cases of sterility can be 
cured by general treatment. Repeated abortions indicate the pos- 
sibility of the syphilitic taint. The existence of this vice in a 



STERILITY. 

Fig. 32. 



117 




Apparatus for Artificial Impregnation. 



marked degree is an almost certain obstacle to the chances of gesta- 
tion being completed, and it must therefore receive continuous and 
persistent treatment for a period of at least two years. 



ANOMALIES OF THE FEMALE GENERATIVE ORGANS. 



By anomalies of the female generative organs we mean the con- 
genital (not acquired) partial or total absence, the arrest of, or 
excessive development, or a peculiar formation or malposition of 



Fig. 33. 





2 



Development of the Kxternal Genital Organs— diagrammatic. 1. P, rectum, continuous with All, allantois 
(bladder), and M, Midler's canal (vagina) : .c, depression of the integument below the median tubercle, 
which by its progress inward forms the vulva. 2. The depression has extended inward to become 
continuous with the rectum and the allantois to form the cloaca, CI. 3. The cloaca has split into the 
uro-genital sinus, Su, and the anus, «, by the down growth of the perineal septum. The Miillerian 
canals are fused to form the vagina, I", behind the bladder, B, and the orifice of the urethra, u. 4. 
The perineum completely formed, 5. The upper portion of the uro-genital sinus contracts to form 
the urethra; the lower portion persists and forms the vestibule, an, into which both urethra and 
vagina empty. 




$& W) 



tfalformation Oi the External Genital Organs— diagrammatic. 1. Complete atresia of the vulva: r, 
rectum; g, genital canal; &, bladder, communicating with both. 2. complete atresia of the vulva: 

i , tectum, separated from the allantois; li, bladder, and </, genital canal, distended with urine. 3. 

Un-iii ..I \auona ami i -: ,/. perineum, incomplete; h, bladder; r, vagina, and ;■, rectum, open 

h\ a comiiion cloaca. I. Hypospadias in the female : first degree coincident with byperl rophy of the 



urogenital sinus — that is, into the vest ihule. 



ANOMALIES OF THE FEMALE GENERATIVE ORGANS. 119 

any part of the generative tract, considered first, in general, as 
abnormalities of the external and internal zones; and, secondly, as 
abnormalities in individual organs, dividing them for consideration 
into : 

1. General anomalies of the two zones : true and apparent her- 

maphrodism. 

2. Anomalies of the separate organs : 

a. The external zone : the vulva, labia, nymphse, clitoris, 

and the vagina; hypospadias and epispadias. 

b. The internal zone : the uterus, Fallopian tubes, and 

ovaries. 

I. General — Total Absence of Either or of Both Zones. 

There is on record no authentic case of entire absence of both 
external and internal generative organs in the same person. Occa- 
sionally there have been reported cases of acephalic fetuses, prema- 
turely born, in which no trace of generative organs could be dis- 
covered, but these are extremely rare ; more than that, no authentic 
cases have been proven, although many have been described, in 
which the external genitals have been entirely lacking ; in every 
case properly examined rudimentary processes have been found. 

Foville reported a case in which there was absence of the nym- 
phse, labia, and clitoris, with a fusion of the vestibule ; a minute 
opening only was present, the outlet of the urogenital canals, 
through which the urine and menstrual fluid passed. In this 
case Klebs claimed there was fusion of the raphe. Meckel has 
described some old eases of entire absence of the genitals, but in 
these cases there was a depression or an elevation where the vulva 
should have been, and the details of the examinations were so 
meagre that they cannot be called authentic cases. The complete 
absence of the internal organs of generation is an extremely rare 
anomaly, if it exists. Kussmaul describes a female in which the 
most careful examination showed no signs of uterus, ovaries, or 
tubes, and where the vagina existed as a minute opening. Emmet 
records a case where a woman, so called, had been married for two 
years, but had never menstruated. An examination showed that 
sexual intercourse had been carried on through the urethra and 
into the bladder. In this case he was unable to discover any signs 
of vagina or uterus. 

Other writers have described similar cases, but in few of them 



120 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

has an autopsy been obtained, and then, in each case examined, rudi- 
mentary organs have been discovered. 

True Hermaphrodism, in which one or more of the generative organs 
of the male and female are present in the same individual. 
Dohrn denies the existence of true hermaphrodism in the human 
race, however common it may be in the vegetable and animal king- 
doms, while Skene mentions Hildebrant and Bannon as having 
authentic cases which they reported. Klebs classified hermaphro- 
dism into — 

1. Bilateral, where the ovaries and testicles exist simultaneously 

on both sides ; 

2. Unilateral, where both ovary and testicle are present on one 

side at least ; 

3. Lateral, where the ovary and testicle are present on different 

sides. 

Ahlfeld claims that there has never been on record a proven case 
of unilateral hermaphrodism, and that he has his doubts about the 
existence of bilateral hermaphrodism. Zweifel agrees with him in 
this. . Ahlfeld mentions the cases reported by Heppner and Schnell 
of bilateral hermaphrodism, but there was so much difference of 
opinion about them that certainly nothing definite was proven. 
Zweifel quotes the following men as having recorded cases of lateral 
hermaphrodism : Sue, Barkow, Berthold, Bannon, Meyer, Gruber, 
and Klotz. Courty divides true hermaphrodism into lateral, trans- 
verse, and vertical or double, and says : " Two cases are now recorded 
— one by Bokitansky and another by Heppner — which prove to 
a certainty that the simultaneous presence of organs, characteristic 
of both sexes, may be found in the same individual, not only the one 
on one side, the other on the other, but simultaneously on the same 
side." The autopsy in Rokitansky's case in 1869 showed two ova- 
ries with their tubes, a rudimentary uterus, and one testicle, with 
vas deferens containing spermatozoa. This individual menstruated 
regularly, and had an imperforated penis and a bifid scrotum. The 
case of Heppner, the second one he reported, was the autopsy upon a 
six weeks' infant, in which he found ;i complete internal generative, 
apparatus, a penis, hypospadias, and two supernumerary glands, 
which he pronounced to be testicles. Slavjansky declared that 
these two supernumerary glands were ovaries, and not testicles. 

Zweifel says of congenital hermaphrodism : " In not a single 



PLATE XII. 




%. 






Pseudo-external Bilateral Hermaphrodisrn. 



ANOMALIES OF THE FEMALE GENERATIVE ORGANS. 121 

case as yet, however, have spermatozoa been found in hermaphro- 
dites, the ejaculations consisting simply of such a fluid as even 



Fig. 35. 




Pseudo-hermaphrodism proper. External genitals of Julia D (man). Feminine appearance of the 

parts with the penis raised and the thighs separated : b, frasnum ; mu, meatus ; ov, vulvar orifice. 



females secrete on irritation of their sexual organs." Still, it is 
certainly a fact that the tendency in the majority of cases is toward 
the male type, and that nearly all, if not all, authentic cases have 
been of lateral hermaphrodism. In apparent or pseudo-hermaphro- 
dism the female may simulate the male type by an abnormal devel- 
opment of the clitoris and a hernial descent of the ovary into the 
labia, as described by Auger ; or, in cases of hypospadias, the male 
may resemble the female, the fissure of the corpora cavernosa being 
taken for a vagina, and the penis, which in these cases is nearly 
always atrophied, being mistaken for an hypertrophied clitoris. In 
some of the cases described, the non-descent of the testicles into the 
scrotum made the diagnosis more difficult. Vice versa, Junie, Coste, 
Engel, and Huguier describe cases of hypospadias in the female, 
with hypertrophy of the clitoris, that were regarded and reared 



122 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



as males. Leopold recorded a case in which a male pseudo-her- 
maphrodite was married as a female. There existed, in place of the 
vagina, a cul-de-sac. Oldham cites two cases where herniated ova- 




Pseudo-hermaphriHlisin proper. External organs of Louise B (man): g, glans ; b, frsenum ; ov, vul- 
var orifice ; hy, hymen ; /, fourchette ; pi, nymphse ; gl, labia majora. 

ries in persons who had never menstruated gave rise to a mistake 
of sex. Ricco and Steglehuer reported cases of the same sort. 

II. Anomalies of the Separate Organs — the External 
Zone; Vulva, Labia, etc. 

Louis and Petit mention cases of acephalic monsters in which 
there was complete absence of the vulva. Two cases were described 
by Riolan in which the left labium majus was lacking. Kussmaul 
describes Rossi's case, where the vagina existed as a most minute 
opening, and Foville's case, referred to before, showed an absence 
of labia, nymphse, and clitoris. Coste and Seggel have on record 
rases where the labia were undeveloped, being represented by lit- 
tle ridges of integument. 






AN03IALIES OF THE FEMALE GENERATIVE ORGANS. 123 

Meckel, Granville, and Mayer have cited instances where the 
labia majora have been rudimentary or lacking. There are, of 
course, many cases on record of a lack of development of the 
external genitals as a whole, and where the parts, even in adult 
life, resemble those of an infant. Cases of hyper-enlargement 
or multiplication of the labia are not so rare. Meissner, Morga- 
gni, Winckel, and Neubauer mention cases where there have been 
three and fourfold labia and nymphse. Zweifel quotes Halle as 
recording a case in which the nymphse covered the anus. Among 
certain tribes (the Hottentots, for example) the labia are of enor- 
mous size and hang down for six or eight inches (the Hottentot 
apron). 

Arnaud and Morpain describe cases of absence of the clitoris, 
and Mannosi refers to a case in which an autopsy showed no sign 
of even a rudimentary clitoris. Zweifel mentions Meissner as quot- 
ing unquestionable cases of congenital hypertrophy of the clitoris, 
reported by Tulpius, DeGraaf, Zachias Avicenna, Plater, Rhodius, 
and Panarali. Frick, Armand, and Coste report cases of hypertro- 
phy where the clitoris was as large as an erect penis. Ahlfeld 
describes several cases of this sort in full. The clitoris, like all 
the other generative organs, may remain in an undeveloped state, 
and yet, according to some writers, may not be, properly speaking, 
an anomaly. 

Congenital hypospadias and epispadias are not uncommon in 
the female. In epispadias the clitoris is split at its upper or lower 
portion, as the case may be. Roser, Schroder, Gosselin, and Teste- 
lin have reported cases. Roser's and Schroder's were operated upon 
and cured by Moricke and Frommel. In hypospadias the posterior 
wall of the urethra is lacking, the canal opening upward into the 
vagina. There is seldom a fissure of the clitoris in cases of hypo- 
spadias. 

The Hymen. — Roze, in his interesting thesis, goes fully into the 
question of the abnormalities of the hymen, and Courty, in his work, 
discusses the question in full. Illustrations are given c pf the d li- 
ferent anomalies. 

Zweifel writes that " very likely, atresia of the hymen is not 
an anomaly of development," and quotes Briesky as expressing 
the opinion, that it is simply the secondary obliteration of a pre- 
viously formed canal, through defective hornification of the super- 
ficial epithelium. Briesky in his chapter on congenital malforma- 



124 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

tion says : " Hymenial atresia, however, is excessively rare as an 
acquired condition," and he states that he has but once met 
with a true atresia hymenalis in a new-born girl. The genitals 
were otherwise normal in this child. He gives an interesting list 
of eighteen cases of hymenalis and vaginal atresia operated upon 
and cured by him. Zweifel himself had a case of " atresia hymen- 
alis " where the entire vagina was affected by this epithelial adhe- 
sion ; so, too, the cases reported of double hymens are simply adhe- 
sions of the epithelial cells. 

The Vagina. — Atresia or absence of the vagina may be par- 
tial or total, and, according to Courty, may coexist with absence 
of the uterus or with a normal uterus. Cook, Yagishita, Matters- 
dorf, and Barsony have lately recorded cases of congenital vaginal 
atresia. Atresia of the vagina, to quote Briesky, is probably due to 
a secondary adhesion, as is atresia of the hymen, rather than to 
an anomaly of insufficient formation. Bokal and Zweifel seem 
to agree with him in this theory. Briesky goes on to say that the 
arrest of development may be of two kinds — cloaca, due to defect- 
ive division between the rectum and bladder, and the existence of 
intravaginal septa. The cloaca may be complete or incomplete ; 
the latter may be uro-genital or recto-genital. " The atresia of 
the upper and middle portion of the vagina is due to the loss 
of the existing lumen of the divided or united vaginal portions 
of Muller's ducts," but when the lower vaginal part is wanting, 
there may be a total absence of the lower part of the Mullerian 
ducts. Courty describes complete uro-recto- vaginal cloaca in a 
new-born child, and a recto-vaginal cloaca in a girl of sixteen, who 
had an imperforate hymen and menstruated through the anus. He 
cites several other cases of cloaca more or less severe. There may 
be a transverse division of the vagina, the so-called double hymen, 
or a longitudinal division, either from right to left — a rare anomaly 
— or from before backward, the so-called double vagina. These 
divisions may be complete or incomplete. Puech states that more 
than one hundred cases of this anomaly have coexisted with anom- 
alies of the uterus, and less than fifteen have been reported with a 
normal uterus. Great differences exist as to the length and breadth 
and shortness of normal vaginas; anomalies of excessive length, 
etc., have been described by Toison, Scanzoni, Courty, Zweifel, and 
Puech. 



ANOMALIES OF THE FEMALE GENERATIVE ORGANS. 125 

Internal Organs (the uterus, Fallopian tubes, and ovaries). — 
The Uterus. — The division of uterine anomalies is as follows : 
I. Defectus uteri. Total absence of the uterus. 
II. Rudimentarius uteri. Rudimentary uterus. 

III. Uterus unicornis. The one-horned uterus. 

IV. Uterus bicornis. The two-horned uterus. 
V. Uterus septus. Two- chambered uterus. 

VI. Uterus duplex or didelphys. The double uterus. 
VII. Defectus et rudimentarius cervix uteri. Defective and rudi- 
mentary cervix of the uterus. 
VIII. Abnormalities of position. 
Borner gives as the probable ultimate causes of the faults of 
development in the uterus the following : 

1. Interference with the approximation of union of the two 
lateral organs which go to form the uterus. 

2. Interference with the disappearance of the vaginal septum 
formed by the union of the median walls, which gives the double- 
cavity uterus. 

3. Nutritive disturbances in the original genital structure. 

4. The fact that the obstacle to development may occur so early 
in fetal life that the foundations of a part of the uterine structure 
are not laid ; in this way a segment on one or both sides may be 
missing. Hart and Barbour give as the two causes arrested 
development and arrested growth, which together operate to pro- 
duce malformations. 

I. Defectus Uteri. — Kussmaul and Borner claim that the uterus 
is rarely if ever entirely wanting, and that an autopsy on any case 
will reveal some vestige of a rudimentary or atrophied organ. 
Courty quotes a case in which there was claimed a total absence 
of the internal organs of generation. Borner, Quain, and Stegle- 
huer report cases in which, on the living subjects, they could find 
no trace of uterus, ovaries, or tubes. In monstrosities in which no 
uterus was found, no traces of the Mullerian ducts were discovered. 

II. Uterus Rudimentarius. — Veit, Langenbeck, and Nega have 
described cases where the uterus seemed little more than a thicken- 
ing on the posterior vesical wall. Cases have been reported varying 
from this highest grade of deformity to the approach of the normal. 
The ovaries in these cases are generally present, and are often nor- 
mal ; there is no trace in the more pronounced cases of any periodic 
ovulation. Borner, Tauffer, Langenbeck, and Peaslee report cases 



126 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



where relief was sought for pains and backache occurring regularly 
each month, but without ever being accompanied by menstruation. 



Fig. 37. 




Cervix and two Horns : a, bladder cut open ; bb, ureters ; cc, 
■ fF pnrniiD. of the nt.prns : an. rnmirl ligaments ; hh, ovariei 



Solid Rudimentary Uterus, consisting of one Cervix and two Horns : a, bladder cut ope 
umbilical arteries; d, rectum ; e, cervix ; ff, cornua of the uterus; gg, round ligan 
with follicles ; i, rudiment of the Fallopian tube ; kk, peritoneal duplicature of the 



In a case of this sort Leopold operated and removed a rudimentary 
left uterine cornu and ovary with a perfect recovery. 





Uterus Bipartitus : a, closed vagina; 6, cervix uteri ; 
cc, cornua of the uterus ; del, hollow expansion of 
the cornua; cc, atrophied ovaries: f, Fallopian 
tube ; gg, round ligaments ; hh, broad ligaments. 



I lljaill lli I lent 



III. Uterus Unicornis. — An anomaly in which only one horn of 
the uterus has been developed, the Miillerian duct on the opposite 
side being atrophied, absent, or undeveloped. In this case the ute- 
rus is elongated and lies, obliquely bent, to one or the other side. 
Pregnancy in these cases occurs naturally, if the vagina be normal, 
and the shape of the uterus causes the fetus to lie vertically. In 
a case of Moldenhauer's, on delivery, rupture of the uterine walls 
occurred. Hegar, Frankenhausen, Borniski, and Borner describe 
cases where one cornu was atrophied. 

Koeberle performed Csesarean section and removed piecemeal a 
fetus from a right uterine horn. 

Salin, Litzmann, and Sanger performed abdominal sections for 



ANOMALIES OF THE FEMALE GENERATIVE ORGANS. 127 

the removal of diagnosed dead fetuses, and found that in each 
case conception in a uterus unicornis had occurred. 

Fig. 40. 




"Uterus Unicornis with rudimentary cornu : LH, Lo, LT, and L Lr, horn, ovary, tube, and round ligament 
of the left side ; RH, Ro, RT, and R Lr, those of the right side. 

IV. Uterus bicomis is the result of a non-union of that part of 
the Miillerian ducts which goes to form the body of the uterus, 
leaving a division or fissure, more or less pronounced, from before 
backward over the fundus, separating the cornu, which projects at a 
more or less obtuse angle, each cornu having its distinct cavity. The 




Uterus I'.iciuiiis 



uterus in these cases is often twisted on its long axis, and may contain 
a partition-wall. Cases have been recorded in which the uterus and 
the cervix have been divided into two separate compartments. The 
two horns are seldom equally developed, but the ovaries and tubes 
are generally normal ; the vagina, however, often has the same 
duplexity. There may be atresia of one of the horns. In cases 
of extreme separation of the two halves, menstruation does not 
always occur simultaneously from the two cornu, and in some cases 
a pregnancy in one half does not interfere with menstruation from 
the other. Henderson made interesting notes on a case of this kind, 
watching the woman for sixteen years and delivering her of six 



12X 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



children. In two or three of these pregnancies she menstruated 
during the whole term. 

Gouterman reports a case in which pregnancy occurred in each 
horn separately and at different times. 




Bicorn Unicervical Uterus. 

V. Uterus septus is a uterus normal in shape and generally in 




Uterus Septus : uri, tubes; lib, I'uikIus uteri ; ccc, septum; 
os; ff, external wall of the two cervices; 



1 cavities of tbe two uteri ; 
L'rnul orifice ; hh, vagina. 



size, but internally divided into two cavities by a partition. This 
partition may be complete, extending from the external os to the fun- 



ANOMALIES OF THE FEMALE GENERATIVE ORGANS. 129 

dus, or may be incomplete and only extend part of the way. In this 
anomaly the ducts of Miiller have coalesced, but the partition-wall 
has not been absorbed. Blackwood recorded a case in which men- 
struation occurred alternately from either side. This abnormality 
interferes very little with pregnancy, but if the placenta is attached 
to the thin partition- wall, profuse hemorrhage may occur. Huge 
recently split the partition-wall in a woman who had miscarried 
twice, and in the third pregnancy she was delivered at term. 

VI. Uterus duplex or Didelphys is the development of two com- 
plete and independent uteri, with no partition-wall and no adhe- 
sions. Mayrhofer claims that this anomaly can only occur with 




Didelphic Uterus and Divided Vagina : a, right segment ; b, left segment ; c, d, right ovary and round 
ligament ; /, e, left ovary and round ligament; g,j, left cervix and vagina; k, vaginal septum: h, i, 
right cervix and vagina. 

changes that would render life impossible, and so thinks that cases 
reported as duplex are only cases of septus. 

In Olliver's interesting case the autopsy showed two distinct 
uteri, separated from each other by. folds of the intestines; and 
Olliver quotes Bonnet as having had the same sort of a case. 
Heitzmann's case was similar to this, with the additional fact that 
not only the bodies of the two uteri, but also the two cervices, were 
widely separated. In all these cases there was but one set of 
appendages to each uterus, and but one broad and lateral ligament. 

Winckel and Cassau have reported similar cases, and Schroder 
one in which the rectum was between the two uteri. Menstruation 
has been in these cases normal. Satschowa reports a case where 
both cavities were gravid at the same time. 

9 



130 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

VII. Abnormalities of the cervix uteri are common both in the 
size and shape of the canal and the external os, and in the size and 
shape of the cervix itself. These are well described by Courty in 
his work on the uterus, ovaries, and tubes. Winckel and Heitz- 
mann have recorded cases of a double os uteri, or a normal uterus 
and cervix with the external os divided into two parts by an unab- 
solved partition. Bonier describes a case of his own of complica- 
tion of the cervical cavity, which appeared at first sight like a cervix 
within a cervix, and quotes a case of Breisky's at Berne which was 
of the same kind. Bonier was the first to describe this anomaly, 
and considers it extremely rare. 

VIII. Abnormality of position is caused probably by the insuf- 
ficient development of one of the Miillerian ducts, although united 
to its opposite duct ; again, there may be a difference in the position 
of the two Miiller's ducts, one being lower than the other, so that 
the fundus when developed is bent to the right or left as the case 
may be, or even twisted upon itself. 

Kussmaul found this malposition in an autopsy upon a child, 
and in his case, one of the lateral ligaments was abnormally short. 
Fetal inflammations may play their part in these abnormalities. 
Sterility generally is present in these cases. 

The Abnormalities of the Fallopian Tubes. — The entire absence of 
the Fallopian tubes rarely occurs, Courty says, even when the uterus 
is entirely absent. In cases of uterus unicornis, both the tube and 
ovary are lacking on the undeveloped side. Winckel, in post- 
mortem examination of 500 female bodies, found the tubes to be of 
unequal length in 25 ; in 3 cases the tubes were from 4i to 5 inches 
long ; and in 2 cases he found accessory tubal ostia. Klob and 
Rokitansky have called attention to the differences in form of the 
ends of the tubes, and described supplementary openings that some- 
times occur at or near the ends. Hennig described three cases of 
accessory tubes, and Bandl reported a case in which the tube was 
normally developed, but imperforated. Congenital abnormalities 
of position and development of the uterus naturally give rise to 
abnormalities of position of the tubes, and congenital hernias of the 
ovaries carry the tubes with them as a rule. Olshausen says : " In 
some, the Fallopian tube is defective, and its internal extremity is 
alone developed ; its abdominal extremity is destitute of fimbria 
and obliterated." Keppler describes a supernumerary tube with 
a corresponding third ovary, that occurred in one of his cases. 



ANOMALIES OF THE FEMALE GENERATIVE ORGANS. 131 

Ovarian Anomalies. — Congenital absence of both ovaries, like 
absence of both tubes, probably occurs only in non-viable mon- 
strosities, according to Olshausen, and reported cases in individuals 
cannot be considered authentic, since torsion and constriction may 
cause such marked atrophy as to leave little, if any, vestiges of the 
once-present ovary. Rokitansky demonstrated this condition in 
several of his cases. Absence of one ovary occurs only in cases 
of uterus unicornis. Grohe first reported a case of supernumerary 
ovary, and mentions a second case described by Klebs where the 
constriction of a band cut the ovary into two halves, each contain- 
ing Graafian follicles in a rudimentary state. 

Sinety's autopsy on a new-born babe showed six appendages to 
one of the ovaries : one of these appendages showed normal ovarian 
structure, while the rest were cystic. 

Keppler, as mentioned before, found a third ovary and tube in 
one of his cases. Kochs, Lumniczer, and Winckel describe similar 
cases. Beigel found appendages to normal ovaries containing 
ovarian tissue 8 times in 350 post-mortems, and Winckel 18 times 
in 500 autopsies. Waldeyer found 6 in one ovary. These extra 
ovaries are generally bilateral ; their peculiar feature is their imper- 
fect development. Klebs declares that ovaries, in which germinal 
epithelium projects into the stroma, with separation of these tubes 
from the surface epithelium, without the development of follicles 
and ova, are similar in many ways and in appearance to testicles. 



GENITAL TUBERCULOSIS. 



Genital tubekculosis in the female may exist as a primary 
affection, although in the great majority of cases it is secondary to 
tubercular disease elsewhere. As a primary affection it has been 
found in from 5 to 15 per cent, of cases. J. Whitbridge Wil- 
liams collected statistics showing genital tuberculosis in from 1 to 
8 J per cent, of autopsies on phthisical women, and in 1 of every 12 
abdominal sections for inflammatory disease. Cohabitation with 
one affected with tuberculosis of the genital, urinal, or intestinal 
tract may be the cause. Inoculation may occur by means of an 
instrument, finger, clothing, or other foreign body contaminated 
with the germs. It seems possible that the tubercle bacilli may 
enter the blood and obtain their first foothold in the diseased 
genital organs. 

As a secondary affection genital tuberculosis may be caused by 
excursions of the germs from distant parts, through the blood- or 
lymph-channels ; by direct extension, as from the peritoneum, 
intestines, or urinary organs ; or by auto-inoculation through the 
infected urinary, alvine, pulmonary, or other excretions and dis- 
charges. 

Tuberculosis op the Vulva. 

Primary tuberculosis of the vulva is almost necessarily a skin 
affection, and occurs only in the form of lupus, unless we except 
those cases of coincident vaginal and vulval ulceration observed by 
Deschamps, Chiari, and Zweigenbaum. In these cases the disease 
was probably of vaginal origin, and not a true tuberculosis of the 
vulva. 

Lupus begins on the cutaneous portions of the vulva in the form 
of hard masses, of a dark-red, livid color, imbedded in indurated skin. 
Sometimes there will be one large mass, sometimes a more diffused 
infiltration with several masses. On the dull-red or yellowish- 
brown surface or surfaces, brighter red, projecting tubercles appear. 



GENITAL TUBERCULOSIS. 



133 



which in a few weeks or mouths commence to ulcerate and exude 
a serous fluid. When there is but a single mass, the whole surface 
assumes the appearance of a raised, unhealthy ulcer, while, in the 
diffuse variety, the ulcers may be separated. The base is hard and 
does not usually bleed easily, and is composed of friable, unheal thy- 




Lupus hypertrophiciis et perforans of the Vulva. 

looking granulation-tissue. As the disease spreads it takes in more 
and more of the skin, and finally invades the lymphatic glands and 
internal organs. The course is usually slow, extending over years, 
and in old cases is often accompanied by cicatricial contraction in 
places, thus producing more or less deformity. The general health 
does not, at first, suffer, but the disease, after lasting several years, 
usually ends fatally. 

The diagnosis presents no real difficulty, for its slow develop- 
ment and chronicity distinguish it from cancer and malignant dis- 
ease, while the ulcerative characteristics differentiate it from ele- 
phantiasis. 

The treatment should always be radical. When possible, the 



134 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



diseased parts should be extirpated. When not, a thorough curetting 
with a sharp instrument, followed by a disinfection of the wound 
with strong acid, may be tried and repeated as often as the disease 
returns. Free incisions or linear scarifications favor cicatrization 
and healing. Deep cauterization by means of electro-puncture is 

Fig. 46. 




Lupus of the Vulva. 

the most satisfactory way of treating many cases, for all parts of the 
diseased tissue can thus be reached and cicatrization secured. The 
treatment must be repeated as fast as the disease recurs or redevel- 
ops, until all foci are finally destroyed. 

Tuberculosis of the Vagina. 

Tuberculosis of the vagina is usually secondary, although a few 
cnscs have been observed in which no other foci of the disease could 
be discovered. 

It commences in the form of miliary tubercles, which in time 
break down and form irregular, flat ulcers with sharply-defined 
edges and a depressed grayish or yellowish-gray base, studded with 



GENITAL TUBERCULOSIS. 135 

granulations and covered by caseous matter. An area of hyperemia 
more or less filled with miliary tubercles usually surrounds the 
ulcer. 

Tubercular fistula may result either from the vaginal ulceration 
extending into the connective tissue, and thence into the rectum, 
bladder or perineum, or from perforating rectal or vesical ulcers. 
We have been able to trace one fistula to ulceration of the Fal- 
lopian tube into the connective tissue and out at the skin over 
the perineum. 

The usual seat of vaginal tuberculosis is in the posterior fornix, 
which probably becomes infected by the uterine secretions. It has 
been found that peritoneal or tubal tuberculosis may, either of them, 
infect the vagina without infecting the intervening structures, al- 
though in the majority of cases the uterus also becomes infected. 

A case of secondary infection from the umbilicus has been reported. 

When the poison is introduced from without, the lower portion 
of the vagina may become first attacked. 

The vaginal epithelium resists the invasion of tubercle bacilli 
until it becomes injured or abraded by trauma or the presence of 
irritating fluids or secretions. 

The character of the ulceration and the fact that miliary tuber- 
cles in the vaginal walls are almost invariably connected with tuber- 
culosis elsewhere, will prevent them becoming mistaken for granular 
vaginitis. Chancres may be mistaken for tuberculous ulceration 
of the vagina, but the clinical history and course of the disease soon 
clear up all doubt. A microscopic examination may sometimes be 
required to differentiate between it and carcinoma. 

The treatment should be as radical as possible when the vagina 
alone is affected. Excision of the diseased part and cautery of the 
wound should be done whenever practicable ; otherwise, curetting 
and cautery. When, however, as is usually the case, the uterus and 
Fallopian tubes are affected and radical measures give no hope of 
prolonging life, palliative treatment only will be indicated, such as 
astringent and antiseptic vaginal douches, local applications to 
improve the character of the ulcerations, incisions, and cleaning of 
fistulae, general tonics, etc. 

Tuberculosis of the Cervix Uteri. 
But few cases of tuberculosis of the cervix alone have been ob- 
served. The cases are also rare in which the body of the uterus is 



136 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



at the same time affected, the majority of cases being found in con- 
nection with tuberculosis of the vagina. 

It occurs in the form of miliary tubercles, ulceration, or a com- 
bination of both. It is supposed that the mucous membrane of the 
cervical cavity, which does not have the protecting pavement epi- 
thelium of the vagina] portion and vagina, can become infected 
without having a previous lesion. The first stage is one of catarrhal 
inflammation, with the presence of small tubercles under the mucous 
membrane, usually too small for recognition clinically. As the 
disease advances the cervix enlarges, and ulceration similar to that 
of the vagina may appear. Small-celled infiltration of the con- 
nective tissue with the characteristic giant-cells, secondary villosities 
on the folds of the arbor vitas, and enlarged glandular cavities 
are found. 

Fig. 47. 




ruberculosis of the Cervix Uteri : g, papillae and superficial vegetation; t. connective tissue containing 

many round evils; r, fissure in tuberculous lissur, in which mav be seen rpilhelioicl cells belonging 
to a tubercular li.llicle; r, giant-cells; /,, epithelial covering of a gland near a tubercular follicle, 
showing large epilhelial cells; „, epilhclial layer formed of elongated cells; lit, mucus contained in 
the gland; 6, greatly elongated epithelial cells of a gland; v, vessel. 

In case of development upon the vaginal portion, the granula- 
tions are for a time covered by normal layers of epithelium, the 
disease develops in the submucous connective tissue, and even 
extends slightly into the muscular layer. 



GENITAL TUBERCULOSIS. 137 

The diagnosis is based upon the presence of tuberculosis else- 
where, the severe grade of the cervical endometritis, the infiltration 
of the cervix, the characteristic ulcerations (similar to those on the 
vagina), grumous discharge, and the microscopic examination of 
the secretions and tissue, with or without the discovery of the tuber- 
cle bacilli. Tubercle bacilli are not always found in the secretions, 
but the nature of the infection can be proven by inoculation into 
the peritoneal cavity of a guinea-pig. 

The treatment, in the beginning, calls for a high amputation of 
the cervix — after extensive infiltration, for a vaginal hysterectomy, 
provided, of course, other of the genital organs are not also affected. 
When extirpation is no longer possible, palliative treatment, such 
as recommended above for vaginal tuberculosis, must be depended 
upon. 

Tuberculosis of the Uterus. 

Tuberculosis of the uterus seldom occurs except in connection 
with tuberculosis of other parts. It is, however, not a rare com- 
plication of general tuberculosis, and is frequently found in connec- 
tion with tuberculous disease of the Fallopian tubes. It has been 
found in about two-thirds of all cases of genital tuberculosis. Like 
cancer of the uterus, it seldom extends below the internal os. The 
puerperal state predisposes to its development. 

Three forms are given : 1, miliary tuberculosis, with or without 
the formation of ulcerations ; 2, chronic diffuse tuberculosis (caseous 
endometritis) ; 3, chronic fibroid tuberculosis. As, however, the 
first variety occurs only as a manifestation of general tuberculosis 
or as the initial stage of diffuse tuberculosis of the uterus, without 
any definite clinical history separate from the general infection, 
and, as the third variety has not been recognized, except on the 
post-mortem table, we will limit ourselves to the consideration of 
chronic tuberculosis or caseous endometritis. 

This form commences as a deposit or deposits of miliary tuber- 
cles in the mucous membrane just underneath the epithelium, with 
areas of inflammation over them. Microscopic examination of these 
areas shows a development of giant-cells, often containing bacilli. 
As the disease develops the epithelium is destroyed, and ulcers are 
formed with a caseous or necrotic base and surrounding infiltra- 
tion of leucocytes. In time those areas increase and unite, and 
the entire endometrium as far as, but not beyond, the internal os 



138 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

becomes the seat of caseous inflammation. The mucous membrane 
is infiltrated with small cells and destroyed, so as to be represented 
by a yellowish, caseous coating covering an ulcerated surface, studded 
with typical tuberculous nodules. The muscular tissue becomes 
hypertrophied, and at last so extensively infiltrated as to destroy 
the firmness and resisting power of the uterine walls. When 
accompanied with stenosis of the cervical canal pyometra may 
result. 

The symptoms are, first, those of ordinary endometritis, with more 
or less thickening of the uterine walls. The discharge, as the dis- 
ease advances, contains cheesy matter that can often be recognized 
by the naked eye. The disease is chronic, and often associated with 
the symptoms of general tuberculosis. 

The diagnosis in the beginning may be difficult. The symptoms 
of chronic endometritis with a grumous discharge, thickened and 
enlarged uterus, salpingitis, and perhaps chronic peritonitis, should 
lead us to suspect the disease. The discovery of tubercles in any 
part of the system adds to the probability. 

A positive diagnosis, however, is usually made, only by a micro- 
scopical examination of the discharge or of the debris obtained by 
curetting. Tubercle bacilli should be sought for, but cannot always 
be found. Inoculation into the peritoneal 'cavity of guinea-pigs 
should give results inside of two weeks. Sterilized glycerin jelly 
may be infected by the mucus. 

According to Paul Petit, the following characteristics, discovered 
in the scrapings of the uterine cavity, prove the existence of tuber- 
culosis : " Interstitial cells which are necrosed or atrophied in a 
diffuse manner or in well-defined lines; giant-cells in greater or 
lesser embryonal nodules, detached from the stroma, and apparently 
developed around the vessels, whose lumina may or may not be 
preserved ; numerous flexible and dilated glands lined with epithe- 
lial cells, which are either readily elongated or have undergone an 
epithelioid transformation." 

Treatment. — If the uterus alone be affected, it should be removed 
through the vagina. If the tubes are affected, they may be removed 
by an abdominal section, and the uterine body amputated at the cer- 
vix at the same time. To remove adherent tuberculous appendages 
and the entire uterus from above would be a difficult operation in 
most instances. There are undoubtedly cases in which both the 



GENITAL TUBERCULOSIS. 139 

uterus and the tuberculous appendages can best be removed by vagi- 
nal section. Further experience will enlighten us on this subject. 

Tuberculosis of the Fallopian Tubes. 

In the great majority of cases genital tuberculosis commences 
in the Fallopian tubes near or at their fimbriated extremity. In 
nearly all advanced cases the uterus, ovaries, or peritoneum, one or 
all, are likewise affected. Tuberculosis of the Fallopian tubes may 
be primary, but it is, as a rule, secondary to peritoneal, intestinal, 
or a part of general tuberculosis. The frequency of this affection 
has only recently been brought to the attention of the profession, 
and many cases of salpingitis and pyosalpinx turned out to be of 
tuberculous origin. The trouble, when better known, may prove 
to be quite a common one. 

Pathological Anatomy. — Tubal tuberculosis begins by the 
deposit, over a limited area or areas, of miliary tubercles immediately 
underneath the epithelium. At first these tubercles are not recog- 
nized by ordinary inspection, and often pass unnoticed when tubes 
thus affected are removed. As there are no symptoms of this stage 
other than those of the catarrhal inflammation, the condition is of 
greater scientific than practical interest. 

Tuberculous salpingitis or chronic diffuse tuberculosis of the tube 
is the form usually diagnosed. In these cases the tubercles may or 
may not spread over the entire mucous membrane of the tube. The 
overlying epithelium is destroyed, and the mucous membrane about 
the tubercles is infiltrated with epithelial cells, more extensively near 
the fimbriated end, where the tubercles are most abundant. Coagula- 
tion-necrosis takes place in spots, and may involve the whole mucous 
membrane in the destructive process, so that the membrane may be 
represented, particularly at the fimbriated end, by a mass of caseous 
materia], lying over granular ragged ulcers or directly upon the mus- 
cular structure. The disease develops slowly, and remains for a long 
time limited to the mucous membrane, but in time invades the mus- 
cular wall, causing hypertrophy and sometimes nodular thickening 
of the walls of the isthmus. The fimbriated end is apt to be closed, 
and the secretions have the appearance of a curdy pus, consisting of 
mucus, cheesy matter, with granular and epithelial debris, and, if 
there be mixed infection, also of pus. In old cases the pus-corpuscles 
may entirely be converted into granular matter, so that neither pus 
nor pus-germs can be discovered. As much as two quarts of puriform 



140 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



matter have been found in the dilated tube, but ordinarily the quantity 
is small, and may consist of only a little grumous fluid or of almost 
solid cheesy matter, which may be partly calcified. The tubal walls 
are thickened, and become attached by dense adhesions to the pos- 
terior surface of the broad ligaments, pelvic walls, omentum, and 




Tubercular Pyosalpinx with Tubercular Ovary. 

intestines. The adhesions and tuberculous deposits usually affect 
the ovary and surrounding peritoneum. 

The ordinary microscopic appearances of 
inflammatory action, are usually present. In 
membrane are found giant-cells surrounded 
tion, tuberculous follicles, degenerating cells, 
cannot always be detected. Williams descr 
tuberculosis of the tube. He says : " It 
forms of tuberculosis in the excessive forms 



tuberculous tissue with 
the folds of the mucous 
by round -cell infiltra- 
etc. Tubercle bacilli 
•ibes a chronic fibroid 
differs from the other 
ition of fibrous tissue 



GENITAL TUBERCULOSIS. 141 

in and between the tubercles. Sections show the lumen greatly 
distorted and a few miliary tubercles scattered through the mucosa. 
There may or may not be accompanying inflammatory changes, the 
main change consisting in the excessive development of fibrous tis- 
sue both within and without the tubercles and the relative absence 
of caseation. The marked feature of this form of tuberculosis 
appears to be its chronicity." 

Symptoms and Diagnosis. — The symptoms are those of ordi- 
nary salpingitis, but with a somewhat different clinical history. We 
would suspect a salpingitis with extensive adhesions, afternoon tem- 
perature, and signs of progressive chronic peritonitis, in a delicate 
virgin, to be tuberculous. A tuberculous family history, or the dis- 
covery of the disease in the peritoneum or in any other part of the 
system, and the absence of any other apparent cause or known' 
beginning of the disease, arouses suspicion of its tuberculous cha- 
racter. Encysted ascitic fluid extending high above the pubes 
indicates tuberculosis in the majority of cases. The ovaries are 
often coincidently affected, and give the usual signs and symptoms 
of chronic ovaritis. A salpingitis in an ordinary healthy woman 
with symptoms of pelvic inflammation dating from marriage, an 
abortion or confinement, with occasional acute attacks of pelvic 
peritonitis which subside so as to leave no temperature, which recur 
as the result of over-exertion or trauma, and which are retrogres- 
sive rather than progressive as long as the patient remains quiet, 
would be considered due to other causes than tuberculosis. In the 
later stages the lymphatic glands of the pelvis may be enlarged. 

Prognosis. — The prognosis is similar to the prognosis of tuber- 
culosis elsewhere. There is always a tendency to spread to the 
peritoneum, ovary, and uterus, and finally to a general infection 
and a fatal termination. Recovery from primary infection through 
fibrosis may, however, take place. 

Treatment. — In cases of primary tuberculosis of the tubes they 
should be removed. When the disease is associated with tubercu- 
losis elsewhere, except in the ovary and peritoneum, the operation 
should only be performed in case the complicating conditions are 
quiescent and the general condition of the patient good. Tuber- 
culosis of the peritoneum, except in an advanced stage, is not a 
contraindication, since abdominal section often has a beneficial 
influence upon it. 



142 an american text-book of gynecology. 

Tuberculosis of the Ovary. 

Primary tuberculosis of the ovary has not yet been described. 
In connection with tuberculosis of the Fallopian tubes and of the 
peritoneum it occurs frequently, more often with the former, but 
has been found in a few instances as a part of general infection, 
without participation of the other organs of generation. 

It occurs in the form of miliary tubercles, caseous masses, or 
tuberculous abscesses. The miliary tubercles have usually been 
found on the surface of the ovary, and in connection with tuber- 
cular peritonitis, have been known to invade the walls of ovarian 
tumors. Adhesions are not usually present, except in the later 
stages, unless there be tubal tuberculosis. 

The symptoms, diagnosis, prognosis, and treatment are insep- 
arable from the tubal and peritoneal diseases with which they are 
associated. 

Tuberculosis of the Peritoneum. 

Tuberculosis of the peritoneum is met with in three varieties, 
namely : 

1. Miliary; 

2. Fibroid; 

3. Caseous. 

The pathology is similar to that of pulmonary tuberculosis ; in 
fact, tuberculosis of the pleura is frequently associated with that of 
the peritoneum. 

The infection may come directly from the blood or from infected 
viscera by way of the lymph-channels. Tuberculous ulceration of 
the bowels is undoubtedly a frequent cause. Tuberculosis of the 
Fallopian tube is found in more than one-third of the cases among 
women, and may be either the cause or the result. 

Miliary Tuberculosis. 

Miliary tuberculosis of the peritoneum may exist in a latent 
or an acute form. It may develop in a gradual, subacute manner 
without active symptoms or with none at all, and go on to the 
development of fibroid tuberculosis, and not be discovered until the 
peritoneal cavity is opened, on account of some other disease, either 
during life or post-mortem. 

Acute miliary tuberculosis consists in a development of miliary 



GENITAL TUBERCULOSIS. 143 

tubercles in the layers of the peritoneum, with coexistent peritonitis. 
The peritoneum about the deposits may be slightly injected or of 
a raw-beef-red color, with loss of the normal lustre. The tubercles 
may be confined to the intestinal coils and mesentery or may be found 
upon the parietal layer and omentum. Ascites of a deep yellow or 
bloody tinge, without adhesions, may be present, or adhesions may 
form and either limit or encapsulate the fluid. A fibrinous exudate 
is formed on the viscera after a time. The intestinal coils may become 
adherent to one another or to the parietal peritoneum. The omentum 
may be adherent to the abdominal walls, or to the intestines, or to 
both. The adhesions are usually frail and bleed freely upon being 
separated, although the bleeding, which is capillary, soon stops. On 
account of the tendency to effusion the adhesions are not usually 
extensive. Tubercles may be found on some of the organs, such as 
the liver, spleen, or Fallopian tube. 

Symptoms. — The symptoms may develop suddenly or gradually. 
In the former case the patient enjoys pretty good health until over- 
taken by an attack of acute peritonitis. Prodroma, such as loss of 
appetite, disordered digestion, loss of flesh and strength, elevated 
afternoon and subnormal morning temperature, occasional abdom- 
inal pains, and perhaps tymj>anites, may not have been sufficient to 
attract attention. 

Upon the supervention of the acute attack, the temperature goes 
np to 102° or 103° F. in the afternoon, usually with morning 
remissions, vomiting, and sometimes diarrhea, acute abdominal 
pains and tenderness, and tympanites. The symptoms usually sub- 
side in a few days, but not completely ; some intestinal or gastric 
disorder, some afternoon temperature, some tenderness, and some- 
times a little ascites, remain. Pleuritic pains with accelerated 
respiration may complicate the symptoms. 

Usually this condition of partial cure remains for a while, and 
may be followed by a more or less complete recovery so far as the 
symptoms are concerned, or by other attacks, with development of 
the symptoms of caseous peritonitis, persistent gastric and intesti- 
nal disturbance, emaciation, and the usual general symptoms of 
advanced stages of tuberculosis. 

In case the disease develops gradually, tympanites, abdominal 
pains and tenderness, afternoon elevation of temperature, indiges- 
tion, attacks of diarrhea, emaciation and weakness gradually 
become more pronounced and more persistent. The abdomen may 



144 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

be greatly distended and everywhere resonant, or may show evi- 
dences of ascites. These symptoms may at any time develop into 
an acute attack of general peritonitis, or gradually merge into the 
caseous variety, or exhaust the patient in the subacute stage. 

Special symptoms are often observed that have reference to 
infection of the affected viscera. Thus we may have slight icterus, 
hepatic pain, and predominant gastric disturbance when the liver is 
affected ; pain in the iliac regions, backache, leucorrhea, metro- 
staxis, hysteria, etc. when the sexual organs are invaded. 

Pigmentation of the skin has been observed in many cases, par- 
ticularly in those of slow development and in the caseous variety, 
and is considered of diagnostic value. 

Diagnosis. — The diagnosis is based upon the prodroma or the 
gradual onset of the local symptoms, the general emaciation, and 
the presence of tuberculosis elsewhere in the system, particularly 
in the Fallopian tubes, pleura or lungs, and upon the presence, 
later, of ascites. The ascites is very prone to take on the appear- 
ance to the naked eye of an ovarian cyst; in other words, the 
bulging in the flanks, that occurs in other varieties of ascites, is 
oftentimes entirely absent, but in its place the abdomen is dis- 
tended into a globular shape, as in cystic disease. This is of con- 
siderable practical value from a diagnostic point of view. 

Prognosis. — The prognosis of miliary peritoneal tuberculosis 
is probably more favorable than that of any other form. Many 
patients get well under good hygienic surroundings and appro- 
priate treatment, while others are apparently cured by an ope- 
ration. 

Treatment. — The general treatment is similar to the treatment 
of tuberculosis elsewhere. Tonics, remedies for the relief of gastro- 
intestinal irritation, rest, massage, a carefully-regulated diet, diges- 
tives, creasote, counter-irritants, often lead to a cure of the perito- 
nitis, and a practical cure of the tuberculosis through fibroid 
degeneration. 

When ascites has resulted, or when miliary tuberculosis exists 
without extensive adhesions, an abdominal incision, with evacua- 
tion of the fluid if present, and the admission of air into the peri- 
toneal cavity, are often followed by a cure. 

Whether light and the dryness attending the removal of the 
fluid cause the improvement, or the removal of the ptomaines of 
the bacilli with the ascites, or the subsidence of the inflammation 



GENITAL TUBERCULOSIS. 145 

which favors the development of the germs, or the mere evacua- 
tion of the fluid with its embarrassing action upon the peritoneum 
and intestinal muscularis, is difficult to determine. We should say 
that the removal of the fluid would be one factor in those cases in 
which ascites is present. This undoubtedly relieves mechanical 
embarrassment, removes some irritant products, and leaves the 
peritoneal absorbents in a better condition to remove the products 
of inflammation, and thus favors fibroid changes. The admis- 
sion of air would also act as a stimulant to the circulation. The 
well-known fact that the bacteria of putrefaction are antagonistic to 
the development of the tubercle bacillus may also have something 
to do with its curative action. It must be remembered that many 
of the cases would have recovered without the operation, and also 
that the care after abdominal sections must do much to relieve the 
peritoneal irritation and inflammation. Probably many of the cures 
reported are instances of temporary improvement. 

The question of drainage after such an operation is an open one. 
If there be but little ascites and no adhesions have been separated, 
drainage can hardly be of use. Considerable ascites of rapid for- 
mation or oozing from separated adhesions would, on the contrary, 
require it. 

In long-standing cases, with fibrinous flakes and some gelatinous 
fluid that may have been encapsuled about diseased organs, the peri- 
toneal cavity should be douched out with a normal saline solution 
(0.6 per cent.). This condition, however, belongs more often to the 
caseous variety. 

Fibroid Tuberculosis. 

As miliary tuberculosis represents the first stage, so fibroid tuber- 
culosis represents the last stage, of the disease. We refer, of course, 
to those cases which do not terminate in caseation and ulceration, 
and which will be considered hereafter. 

The condition usually found is that of old, firm visceral and 
parietal adhesions and fibrous bands of greater or less extent, with 
hard nodules, sometimes whitish, but. more often pigmented, from 
1 to 3 mm. in diameter, and situated either on the surface of the 
peritoneum, in the mensentery, omentum, or in the fibrous bands. 
Although tubercle bacilli may be found in them, there is a scarcity 
of tubercle cellular tissue and an abundance of fibrous tissue. The 
matting together of intestines, omentum, and other viscera, may 



146 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

give rise to localized resistant masses that can be felt through the 
abdominal Avails. 

Symptoms.— Oftentimes there are no symptoms except those ref- 
erable to a previous stage, and these may have been overlooked or 
misinterpreted. 

The usual symptoms are, more or less abdominal distension and 
tenderness, constipation, gastric or intestinal indigestion, emaciation, 
localized pains, and evidences of j^resent or past tuberculosis in the 
lungs, pelvic organs, or elsewhere. The tenderness is not so great 
but that a careful palpation of the abdomen may be made. The 
temperature ma y be subnormal for weeks at a time, or, if there be 
much disturbance in the abdomen, may rise to 100° or even 102° F. 
in the afternoon, and fall to 97° or 98° F. in the early morning- 
hours. Night-sweats are not usually persistent, if indeed present, 
unless there be also some more active form of the disease in the 
system. In many cases, however, the symptoms are complicated by 
tuberculosis of other parts, and the patient usually dies of general 
or pulmonary tuberculosis, rather than peritoneal. In many cases 
the local and general condition improves, the symptoms subside, 
and the patient recovers, and may remain in quite good health 
until a new development of the disease, either in the abdomen or 
elsewhere, takes place. 

Diagnosis. — The diagnosis is based upon the symptoms already 
given, upon the mild character of the disease, and the tendency to 
improve, instead of growing gradually worse, as in other kinds of 
tuberculosis of the abdomen. An indefinite resonant tumor or 
tumefaction of chronic character is sometimes found, unaccom- 
panied by ascites. Exudates connected with appendicitis and septic 
salpingitis are differentiated by the characteristic acute symptoms 
that precede them. The presence of tuberculosis elsewhere would 
lead us to susj)ect the true nature of the affection. 

Prognosis. — The prognosis is often favorable so far as the local 
condition is concerned. The chief danger lies in the presence 
of the tubercle bacilli in the system, leading to development of 
tuberculous inflammation elsewhere or in other portions of the 
abdominal cavity. Many cases, however, recover without recur- 
rence. 

Treatment. — The treatment consists mainly in promoting the 
curative process that is already going on. If there be but few 
-Yinptoms, ordinary hygienic management, tonics, change of occu- 



GENITAL TUBERCULOSIS. 147 

pation, etc. will be sufficient. Gastrointestinal derangement, abdom- 
inal tenderness, tympanites, and emaciation call for more careful 
treatment. The irritability of the stomach should be relieved by 
appropriate remedies, the bowels regulated, and an abundance of 
easily-digested food given. If there be much abdominal tenderness 
and tympany, the patient should be kept quiet, the circulation and 
nutrition maintained by massage and large quantities of good milk 
and cod-liver oil. Counter-irritation over the abdomen and elec- 
tricity in moderate dosage may have some beneficial influence. 
When the symptoms subside, active outdoor exercise and the ordi- 
nary general treatment for tuberculosis should be recommended. 

Caseous Tuberculosis. 

The caseous or ulcerative form of peritoneal tuberculosis gives 
rise to a variety of conditions. The parietal, visceral, and omen- 
tal peritoneum and subperitoneal glandular structure may be the 
seat of degenerating tubercles. In some cases all the abdom- 
inal viscera are agglutinated by caseous tubercular substance 
and false membranes. Sometimes the adhesions include one or 
more small accumulations of yellowish, reddish, or brownish 
serum of variable density, containing flakes of lymph-granular 
debris, and not infrequently pus and blood-corpuscles and tuber- 
cle bacilli, or the entire fluid may be puriform, or one accumu- 
lation may be serous and the other purulent. Pus-collections 
between and over agglutinated intestines or viscera may, by 
ulceration, give rise to intervisceral or external fistulas. Thus 
in children, umbilical fistulas have often been recorded ; in the 
pelvic tuberculosis of women, rectal fistulas ; while, after ope- 
ration and upon the post-mortem table, viscero-abdominal or 
intervisceral fistulas. More often this cheesy infiltration and 
agglutination of viscera are localized, in some part or parts of the 
abdominal cavity, forming a tumor-like mass. Occasionally gene- 
ral ascites coexists with localized deposits, but more often there is 
either none or there is one large encysted accumulation surrounded 
by a capsule of thickened and infected peritoneum and adherent 
intestines. Local abscesses may burrow through adhesions or in 
connective tissue for a long distance, and become surrounded by a 
large area of induration before finding an outlet. 

Among the favorite places for this variety of peritoneal tuber- 



148 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

culosis to show itself are about the liver, the csecum, the omentum, 
and the uterine appendages. 

The peritonitis about the liver is always secondary to cheesy 
tuberculosis of the liver, and is a very rare affection. 

Agglutination of the intestines about the caecum, with cheesy 
deposits and abscess, that burrow across the abdomen, or upward or 
downward, or discharge into the rectum, has been frequently met 
with. Some of the cases described have probably been old cases 
of appendicitis either with or without secondary infection by the 
tubercle bacilli. 

Tuberculosis sometimes attacks the omentum, particularly in 
children, and may retract and roll that membrane in the shape of 
a hard tumor extending across the upper abdomen, or may go on 
to abscess-formation, and either ulcerate externally at the umbilicus 
or into an intestine, or both. 

Pelvic peritoneal tuberculosis in women is usually connected with 
tuberculous salpingitis. The peritonitis, if extensive, generally 
assumes the encysted form, one large cyst reaching up into the 
abdominal region, sometimes to the umbilicus, and almost entirely 
across, with occasionally one or two small separate sacs in the recto- 
uterine pouch and under the appendages. In these cases the append- 
ages and the surrounding exudate form a hard mass that extends from 
the uterine horns to the sides of the pelvis. The solidified append- 
ages, the uterus, upper part of the bladder, pelvic walls, lower 
anterior abdominal wall and adherent intestines are covered by a 
thick, friable, grayish, or yellowish peritoneal exudate, which can 
usually be readily separated from the intestines superiorly, but 
which often adheres firmly to the parts in the pelvis. Tubercle' 
bacilli are frequently found in the tubes, and signs of tuberculosis 
may exist elsewhere in the system. 

Symptoms and Course. — Caseous tuberculosis of the peritoneum 
usually gives the history of repeated attacks of peritonitis, which 
may have been recognized as such or may have been mistaken for 
gastric or intestinal disorders, typhoid fever, pyosalpinx, appendi- 
citis, etc. Between these attacks the symptoms may subside and 
the temperature remain subnormal, particularly in the early morn- 
ing, for weeks at a time, and but little discomfort be felt. Usually, 
however, there is an afternoon rise of temperature to 100° or 
101° F., some tympany and abdominal tenderness, and occasional 
pain in the intestines or pelvis. At the same time the appetite is 



GENITAL TUBERCULOSIS. 149 

impaired, and the bowels either obstinately constipated or alter- 
nately relaxed and constipated, with attendant loss of flesh. In 
more advanced cases there may be occasional or persistent vomit- 
ing or diarrhea, great abdominal distension from intestinal gases 
or ascites, or both together, with marasmus and night-sweats. 
Obstruction of the bowels has been noted in a few cases. Pleu- 
risy is not a rare complication, and pulmonary tuberculosis will 
be detected in most cases before the fatal termination. 

In some cases the nutrition is but little impaired, and only the 
signs of local inflammatory action of the uterine appendages or 
over some other circumscribed area are to be found. 

Diagnosis. — The condition of the patient often simulates that 
of typhoid fever when the tubercles are localized about the caecum. 
The previous history of abdominal symptoms, the absence of the 
typhoid eruption, the preceding prolonged record of a moderate 
afternoon rise in temperature, palpable induration about the caecum, 
and its occasional extension out from the iliac region, tuberculosis 
elsewhere, and the continuance of symptoms after the first three or 
four weeks, with perhaps a family history of tuberculosis, will gene- 
rally help us to arrive at a definite diagnosis, although in obscure 
cases considerable time may elapse before the differences cau be 
made out. 

Appendicitis has a history of short, localized, acute attacks with 
complete intermissions, while the preceding acute attacks of tuber- 
culosis, if severe, are less localized, or, if not severe, are of a more 
remittent character. Extensive tympanites, pronounced derange- 
ment of the intestinal secretions, and the emaciation and general 
symptoms of the tuberculous condition are not usually noticed in 
appendicitis. A mild attack with a moderate rise of temperature 
for a few days, and then a sudden lighting up of general peritoni- 
tis, is characteristic of appendicitis, as is also the localization of the 
exudate and tenderness near the anterior superior spine of the ilium 
on a line extending from the spine to the umbilicus. 

The local signs may be confounded with malignant, or even 
benign, abdominal growths, but the general symptoms will usually 
enable us to decide in favor of tuberculosis. 

Peritonitis accompanying septic salpingitis shows more decided 
regressions, improves more by rest in bed, and has a history that 
points to its septic origin. 

Encysted tubercular peritonitis, particularly that form connected 



150 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

with tubercular salpingitis, may simulate an ovarian cyst. In the 
former case, however, we can detect the enlarged tubes per vaginam, 
and by the bimanual examination detect an intestinal tumor that is 
connected with the diseased appendages. The tumor as felt over the 
pubes is not so firm as an ovarian cyst and gives larger waves of 
fluctuation. The percussion note shades off gradually from dullness 
to resonance. The encysted fluid has not the definitely rounded 
outline of a single ovarian cyst. The afternoon rise of tempera- 
ture, emaciation, and general signs of tuberculosis indicate the 
true nature of the infection. 

Thin-walled parovarian cysts often give the same kind of wavy 
fluctuation, but they are of a definite rounded outline and not con- 
nected with indurated appendages. The percussion note becomes 
resonant more abruptly. 

Prognosis. — The prognosis is usually bad. The disease is no 
longer in the first stage, and tends to local disorganization and 
general infection. A few cases are cured by operation. After a 
fecal fistula has formed an early fatal result may be expected. 

Treatment. — The medical treatment is similar to that already 
recommended for the other varieties, and can only be considered as 
palliative. The surgical treatment consists in the removal of peri- 
toneal fluid by abdominal section with such affected parts (uterine 
appendages, omentum, etc.) as may be practical, the separation of 
such adhesions as may be necessary to evacuate local fluid accumu- 
lations and relieve intestinal paralysis or obstructions, and the dust- 
ing of the parts with about a dram of iodoform powder. 

The removal of the uterine appendages has already been referred 
to. The accompanying sacculated effusions should be removed so as 
to leave the cavity dry, and the false membrane sponged clean of 
all lymph and debris. Sometimes we may have to content ourselves 
with doing this, without disturbing the appendages. When the 
appendages are removed, the integrity of the sac is necessarily 
destroyed at its lower end, and it is then well to remove all of 
the sac that can easily be detached, for fear that it might undergo 
degenerative changes. 

In the first case of this kind operated upon by the author, he left 
the entire sac, excepting the portion removed with the appendages, 
and had for a result a suppuration commencing on the ninth day. 
On the twenty-seventh day a counter-opening was made in the cul- 
de-sac of Douglas. About a week after that a fecal fistula formed. 



GENITAL TUBERCULOSIS. 151 

The patient died seven weeks after the operation, with the fistula 
still discharging pus and feces. 

Profiting by this experience, the upper part of the sac was 
removed in the next case, leaving only a small, firmly adherent 
portion in the recto-uterine pouch, the drainage-tube being removed 
in fifty hours, and the patient cured. The patient eighteen months 
after the operation was teaching school, in better health than for 
years. In three years, however, she was dead. 

The next case had incipient pulmonary tuberculosis, with a his- 
tory of acute attacks of pneumonia and pleurisy. In addition to a 
pint of sacculated peritoneal fluid, an abscess containing cheesy mat- 
ter was found filling the recto-uterine and lateral peritoneal cul-de- 
sac. Both tubes contained cheesy pus. The left was so friable that 
the ligatures cut completely through and could not be reapplied. 
Removed all of the sac possible. Drainage-tube used for thirty 
hours. Recovery without a bad symptom, and passed from obser- 
vation. 

When the disease is up among the intestines and the coils are 
firmly matted together, it is usually better not to separate them, for 
a fecal fistula may already have formed between them or may be 
produced by the operation. Drainage is necessary in most cases, 
but it should usually be made with a glass tube and the tube taken 
out as soon as possible. When intestinal coils have been opened, 
they should, if possible, be sutured and the areas be shut off from 
the general peritoneal cavity by an iodoform-gauze tampon. Even 
in such cases temporary improvement may follow. 

The good results of abdominal section even in caseous tubercu- 
losis are sometimes surprising, and many cures are recorded. Instead 
of the general peritoneum becoming infected, the healthy mem- 
brane seems to help in curing the diseased portions. 



DISEASES OF THE VULVA AND VAGINA (NON-MALIG- 
NANT). 



Hypertrophy of the External Genitals. 

The parts most frequently subject to hypertrophy, whether con- 
genital or acquired, are the nymphce or labia minora. In women, 
with liberal development of subcutaneous fat, the nymphse are often 
entirely concealed by the labia majora. Ordinarily, they project 
far enough for the edges to be seen. Occasionally, however, they 
project like wings folded over the vestibule or unite over the clitoris 
to form an apron, or one or both may be divided into one, two, or 
more folds, forming double, triple, or even quadruple nymphse ; or 
one labium may be larger than the other ; or they may extend down 
and unite in front of or behind the anus, and cover up the vestibule 
so completely as to cause great annoyance, and may even require an 
operation for their removal. Among the Bushmen and Hottentots 
the labia minora often become enormously developed, and hang like 
thick aprons down to the knees. 

Inflammation may result in cases of hypertrophied nymphse 
from the friction of walking, riding, or excessive venery. Sexual 
irritation undoubtedly causes enlargement and even hypertrophy, 
but should not be considered as the usual cause. 

The remedy for these conditions consists in amputation and sew- 
ing up of the edges with fine catgut or, preferably, silkworm-gut. 

The labia majora vary greatly in size in different women, some- 
times projecting like cushions tightly pressed together, and some- 
times consisting merely of loose folds of skin on either side of the 
exposed nymphaj. The latter condition is often found in very thin 
and in old women. Occasionally the labia will extend down so as 
to form a fold in front of the anus, and have even been known to 
surround the anus. A superabundance of labial fatty tissue not 
only conceals the labia minora, but sometimes seems to draw apart 
the folds that form the latter to such an extent as almost to obliter- 
ate i bem. 

The clitoris is relatively larger in children than in adults, because 

152 



DISEASES OF THE VULVA AND VAGINA. 153 

toward puberty the developing labia gradually project over and 
cover it. True hypertrophy of the clitoris is much less frequent 
than of the nymphae. Occasionally, however, the clitoris is found 
to attain the size of a boy's penis, with powers of erection, and when 
accompanied by adhesion of the labia may conceal the sex. An 
amputation may become necessary, on account of the abnormal 
direction of the stream of urine, friction, excoriations, etc., particu- 
larly when occasioning trouble in childhood. 

Fig. 49. 




Hypertrophy of the Clitoris. 



Adhesions of the Labia. 

Adhesion of the labia usually occurs in infancy and in child- 
hood, and occasionally is found in adult life. It consists merely in 
an agglutination of the surfaces without loss of epithelium or 
organic union. Deficient hardening of the epithelium has been 
given as a cause, and comparison has been made with the adhesion 
of the prepuce to the glans in the male. Uncleanliness, irritating 
discharges, and mild forms of inflammation may lead to it. 

It usually causes no symptoms, but may give rise to incon- 
venience by directing the urine upward. Later, menstrual fluid 
may be retained or may be expelled with difficulty. Coitus is 
usually interfered with, although not always. A woman in labor 
in whom the vagina could not be found, although the head was 



154 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

down upon the perineum, was recently observed. What at first 
seemed to be the vagina was an enormously dilated urethra, through 
which the finger easily and painlessly entered the bladder, and 
through which copulation had taken place. The occluding labial 
diaphragm was punctured a little below the urethra in the median 
line, the opening torn large enough to admit two or three fingers, 
and the advancing head accomplished the rest. The puerperium 
was normal, and the parts afterward regained their natural rela- 
tionship. 

In young children it is only necessary to separate the labia forc- 
ibly, and to keep the parts cleansed and lubricated for a few days 
to prevent an immediate recurrence. In older people the best way 
is to introduce a bent sound into the vagina, just under the urethra 
where a small opening can usually be found, and to tear the labia 
asunder from within outward by dragging the sound out between 
them. When such an opening cannot be found, and the parts are 
not separable by moderate force from without, menstruation may 
be awaited. The vagina will then become filled and the labia put 
upon the stretch by the retained fluid. The bladder should be 
emptied, a sound placed in it, a finger introduced into the rectum, 
and a bistoury trocar plunged into the fluid mass, in the median line, 
a little below the urethra. The opening should then be enlarged 
until the finger can enter the vagina, when the adherent labia are 
separated. Subsequent care prevents reunion. 

Organic union of the labia, clue to traumatism or ulcerative inflam- 
mation, has been known to take place and requires operative meas- 
ures similar to the last mentioned. (See " Atresia of the Vagina.") 

Vulvitis. 

There are three varieties of vulvitis, or inflammation of the 
vulva — viz. : simple, purulent, and follicular. 

Si?nple Vulvitis is generally caused by local irritation. Acrid 
vaginal discharges, dirt, accumulated secretions, dribbling urine, 
parasites, traumatism from scratching, friction, and masturbation 
are the most common causes. 

Increased redness with more or less tumefaction and watery or 
mucus discharges are characteristic. 

Burning pain, particularly upon the passage of urine, and per- 
sistent itching are the main symptoms. 

The treatment should be directed to the removal of the cause. 



PLATE XIV. 
Fig. 1. 




Hypertrophy of Right Labium Majus. Fistula of Ischiorectal Abscess, with 
Syphilitic Eruption on Buttocks. 



Fig. 2. 



to 



~* 



'A 



\ 



i I 



The same. Labium suspended. Syphilitic Eruption faded, ai 
specific treatment for two weeks. 



i 



DISEASES OF THE VULVA AND VAGINA. 155 

Copious hot water, or i of 1 per cent, aqueous saline douches, 1 or 
2 per cent, carbolated aqueous douches, or acetate of lead, a tea- 
spoonful in one or two quarts of water, or a tttot or 2Foir solution 
of bichloride of mercury, are useful when acrid or fetid vaginal 
discharges are present. Lotions of acetate of lead, carbolic acid, or 
tannin should be used externally, and may be continuously applied 
on cloths, if the patient can be kept quiet. Or, the oxide-of-zinc 
ointment, to which 5 per cent, of carbolic acid or 2 per cent, of 
menthol is added, may be frequently applied, and often gives great 
comfort and relief. The milder applications should be used in the 
beginning of the attack ; the stronger in the advanced stages. 

Purulent Vulvitis results from the same sources as simple vulvi- 
tis, and is often an advanced stage of the same. Gonorrheal infec- 
tion is a frequent cause. Direct infection by septic matter may be 
the primary cause. 

Redness, tumefaction, and a muco-purulent discharge are always 
present. In aggravated and neglected cases, eroded and ulcerated 
spots are found on the inner surfaces of the labia, and sometimes 
excoriations on the inner surfaces of the thighs. 

The symptoms are the same as in simple vulvitis, but intensified. 
A moderate degree of febrile reaction and restlessness at night are 
often noticeable in children thus affected. 

Although the disease may pass over without treatment, it should 
not be forgotten that there is danger of progressive infection of the 
vagina, uterus, and Fallopian tubes. 

The treatment must have special reference to the septic nature 
of the disease. All that would be necessary, in addition to such 
treatment as has been given for simple vulvitis, is to obtain and 
maintain perfect cleanliness. This requires more care than is or- 
dinarily understood by that term. If we could wash off the pus 
by constant irrigation with plain water, or h of 1 per cent, solu- 
tion of chloride of sodium, or wash the parts every half hour or 
hour with a saturated solution of boracic acid, the pus-microbes 
would soon be exterminated, and a mild form of simple vulvitis 
established, or a perfect cure attained. 

Warm sitz-baths in i or 1 per cent, saline solution, three or four 
times daily, are of great benefit in removing secretions. The parts 
should be bathed as nearly every hour as possible with the saline 
or boracic-acid solution until the tenderness has somewhat sub- 
sided, and then with a weak acetate-of-lead or tannic-acid solution, 



156 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

and the ease treated the same as in simple vulvitis. Cloths wet 
in these solutions may be used at night instead of frequent washings. 
After the discharge is partly checked, dry pieces of absorbent cotton, 
soaked every hour or two and reapplied, after a mild astringent 
or antiseptic lotion has been used and the parts thoroughly dried, 
constitute the very best kind of dressing. 

The stronger astringents and antiseptics, such as a 2 per cent, solu- 
tion of nitrate of silver or a -joto solution of mercuric bichloride, are 
required only in neglected cases and those that cannot be frequently 
dressed. As the parts cannot be cared for as often in the night, the 
mercuric or silver solution may be advantageously used at bedtime. 

Follicular Vulvitis is the name given to the inflammation of the 
glands of the vulva. Sometimes the sebaceous and piliferous glands 
are enlarged and project like minute papillary elevations upon the 

Fig. 50. 




Follicular Vulvitis. 



surface of the labia and prepuce. This enlargement of the separate 
glands is produced by the distension with mucus or muco-pus, which 
may be seen to exude from them. At other times there are no dis- 
tinct elevations, and the inner surface of the vulva is covered by 
an offensive mucus or mueo-purulent secretion. 

The CAUSES are, want of cleanliness, vaginal discharges, pregnancy, 
discharge from malignant disease, and a reduced state of vitality. 



PLATE XV. 







*-*" 










Hypertrophy of both Labia Majora, with hypertrophy of the skin over the perineum and 
buttocks and about the anus. 



DISEASES OF THE VULVA AND VAGINA. 157 

The symptoms differ but little from those of the other forms of 
vulvitis described above. 

The treatment in mild cases is similar to that of .the simple 
and purulent forms. It is, however, more often necessary to use 
the nitrate-of-silver and corrosive-sublimate solutions. The- emp- 
tying of the follicles is necessary to a cure, and may be promoted 
by alkaline fomentations, pressure by means of dry absorbent-cot- 
ton pads, manual pressure, or better by puncturing with a bistoury 
or a bayonet-pointed uterine scarificator. When thus evacuated 
nitrate-of-silver solution or tincture of iodine and glycerin, in 
equal parts, may be applied. 

Inflammation and Abscess of the Vulvo-vaginal Glands. 

Purulent vulvitis or vaginitis is apt to infect the vulvo-vaginal 
or Bartholini's glands. 

Fig. 51. 




Normal Vulvo-vaginal Gland. The labium majus and minus, the sphincter vagina? muscle, and the bulb 
have been partly removed on the right side in order to expose the gland : A A. section of labium majus 
and minus; 2?, gland; C, excretory duct ; C", stylet introduced into the duct ; D, glandular end of duct; 
E, free end of duct; F, section of bulb ; G, ascending ramus of ischium. 

The symptoms are, swelling of the deeper tissues on the inside 
of the lower part of one or both labia, usually one at a time, with 
enlargement, and often a distinct globular tumor that may vary in 
size at different times, as the gland is filled up or has emptied itself. 
In most cases there is a small area of redness around the mouth of 
the gland, just in front of the hymen or its remains, halfway up the 
side. A muco-purulent secretion may exude or be squeezed out. 
In old cases the only symptom may be an occasional filling up of 
one of the glands with a corresponding globular tumor, deeply seated 
in the labium, which persists and gives rise to local pain for a few 



158 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

days, and then discharges more or less gradually, giving no more 
trouble for the time. In such cases there is but little, if any, sur- 
rounding induration. 

The teeatment consists in the ordinary treatment for vulvitis, 
and in hot fomentations to relax the orifice and thus promote the 
discharge. If the tenderness be not too great, evacuation by gentle 
pressure may be attempted. Drainage by means of dilatation with 
a small probe may be adopted in obstinate cases of recurrent accu- 
mulation. 

Abscess of the gland may result from retention of pus. In this 
case the lower outer part of the labium becomes indurated, and pre- 
sents the ordinary characteristics of labial abscess. The pus may be 
evacuated into the cellular tissue of the labium and a labial abscess 
coexist. 

Excision of the whole gland and surrounding abscesses, and sew- 
ing up of the parts by deep sutures will often effect an immediate 
cure. In case the parts cannot be excised, the secreting surface 
should be destroyed by a cautery, the surrounding pus-surfaces 
curetted, and the cavity packed with iodoform gauze and absorbent 
cotton until healed. The external incision should be a large one. 

Labial Abscess has the same etiology and symptomatology as ab- 
scess in the subcutaneous connective tissue elsewhere. The labium 
becomes enlarged with a well-defined indurated mass, extending up 
and down the labium under the hairy surface. After a few days the 
phlegmon gradually undergoes softening at some particular place, 
and an area of redness appears. The affection is very painful and 
calls for energetic treatment. Cold, in the beginning, is anodyne as 
well as sedative. Later, sitz-baths, poultices, or fomentations, fre- 
quently changed, are to be used. On account of the tendency to 
spread, an early evacuation, by incision on the inner surface, is indi- 
cated. In chronic cases connected with the suppuration of the 
vulvo-vaginal gland, all of the pus-secreting surfaces and indurated 
tissue must sometimes be excised or curetted with a sharp curette, to 
get rid of deep-seated sinuses and pockets that resist ordinary treat- 
ment. 

Exanthemata of the Vulva. 

Herpes, Eczema, and Prurigo of the vulva present similar charac- 
istics to the same symptoms in other parts of the body. 

Herpes is usually a transient affection, and requires only that the 



DISEASES OF THE VULVA AND VAGINA. 159 

parts be protected- from irritation. It consists in a group or groups 
of vesicles, without any inflammation of the surrounding skin. 
The inguinal glands are occasionally tender. A saline laxative, a 
bland ointment, or a soothing lotion, and a mildly carbolated or a 
borated vaginal douche, if the vaginal discharges be irritating, will 
usually be followed in a week or ten days by a cure. A powder 
of oxide of zinc and chalk, equal parts, may be used after the vesi- 
cles break. 

Sometimes herpes occurs in the confluent form, covering the 
vulva, and lasting for ten days or two weeks. It is often connected 
with gastro-intestinal disturbances, and may return periodically. 
Uncleanliness is a prolific cause. 

Eczema is characterized by an eruption of vesicles and some 
inflammation of the underlying and surrounding skin. When the 
vesicles rupture a serous fluid exudes which tends to dry on the 
surface and form scabs. If the disease continues, the skin remains 
•red, becomes thickened, and may in time assume a more or less 
cicatricial character. These conditions may spread to the neigh- 
boring skin. Itching is a prominent symptom. The itching that 
accompanies diabetes is apt to be due to eczema. 

In the acute stage, saline or mercurial laxatives, a restricted diet, 
with soothing local applications, such as bismuth powder, a lead 
lotion, cold cream, 1 per cent, carbolic-acid douches, hip-baths, or the 
benzoated oxide-of-zinc ointment with 5 or 10 per cent, of carbolic 
acid added, may be used. In obstinate cases strong solutions of car- 
bolic acid (5 per cent.), or nitrate of silver (2 per cent.), may be 
required to stimulate the circulation of the parts. The scabs and 
secretions should be washed off with almond or other unirritating 
soap before the ointments are applied. Saline and mercurial laxa- 
tives, digestives, iron, arsenic, etc. may be required as for eczema 
elsewhere. Dryness and cleanliness of the parts are essential, and 
friction is to be as nearly excluded as possible. 

Prurigo is a papular eruption causing distressing pruritis, and is 
difficult of cure. The causes are not well understood, although it 
often occurs in unclean and unhealthy subjects. 

Attention to the general health and hygienic surroundings is 
imperative. The carbolized zinc ointment above referred to, with 
the addition perhaps of 2 per cent, of menthol, often affords great 
relief. From a 5 to a 10 per cent, solution of chloroform in oil of 
sweet almonds relieves the itching in some cases, and may do some- 



160 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

thing toward dissolving out the tenacious masses at the bottom of 
the papilla?. A mixture of ether and alcohol (1 : 4) may be used for 
this latter purpose, or chloroform and alcohol (1:4) if well borne. 
Erysipelas and Diphtheria of the vulva should be treated upon 
the same principles as cases occurring in other parts. They are 
rare affections, and occur in most instances in puerperal women 
and new-born children. 

Gangeene of the Vulva or Noma. 

Gangrene of the vulva occurs in poorly-nourished young chil- 
dren living in unhygienic surroundings, and is exceedingly fatal. 
It begins with reddening and infiltration of one of the labia, accom- 
panied by a discharge of ichorous serum, followed by vesication 
and the formation of a grayish-green slough and raj)id gangrene. 
The condition has been likened to noma in the mouth. It is a rare 
disease, produced by infection, and has been known to be infectious. 

If recognized early enough, the parts should be excised, and 
the resulting wound, if not favorable for obliteration by sutures, 
should be frequently disinfected with strong antiseptics and kept 
constantly moistened with a weak antiseptic solution. The vital 
powers should be sustained with alcohol, strychnia, digitalis, and 
frequent forced feeding. 

Pruritus Vulvjs. 

Pruritus Vulvae is usually a symptom rather than a disease, and 
stands for an intense or persistent itching of the vulva, more often 
felt about the clitoris and vestibule, but sometimes extending to 
the surrounding parts. The itching, depending upon palpable or 
visible local inflammatory disease, is not referred to in the consid- 
eration of this affection. It is often a serious trouble, in that it is 
apt to lead young people into the habit of masturbation, but should 
not be confounded either with the irritability attendant upon that 
habit or with nymphomania, 

The causes may be reflex or local. Irritating and indigesti- 
ble foods or drinks may bring on the attacks in some cases by 
reflex action or by vitiating the urine. The rubbing of clothes, 
the friction of walking, and heat of the bed act as exciting causes 
in those predisposed to it. Local congestion, such as occurs about 
the menstrual period, or in certain cases of pelvic inflammation, or in 
early pregnancy, or at the end of pregnancy when the vulval and 



DISEASES OF, THE VULVA AND VAGINA. 161 

vaginal veins are distended by pressure above, or in old people 
with dilated veins, is an occasional cause. Constipation, sedentary- 
habits, portal congestion, oedema, etc., favor it. Irritating dis- 
charges though scanty from follicular cervicitis, carcinoma, 
uterine sarcoma, diabetes, and incontinence of urine, are some- 
times responsible. Parasites may also act in the same way. A 
chronic follicular inflammation that can only be discovered by a 
careful examination is present in many cases. 

The diagnosis is based upon the intermittent character of the 
itching, the absence of local inflammatory or eruptive disease, and 
the discovery of one of the above-mentioned or other. remote causes. 
Oftentimes no cause whatever can be detected. The local symptoms 
are a shiny, red, somewhat cedematous appearance of the parts about 
the vestibule, with perhaps some serous secretion. Later, changes 
may occur as the effect of scratching, such as excoriations, thicken- 
ing of the nymphse, dryness, cicatricial spots, and furuncles. 

The treatment should of course depend upon the cause, which 
must, if possible, be removed. When dependent upon diabetes or 
incontinence, the parts should be protected from contact with the 
urine by some powder or ointment kept constantly applied, such 
as bismuth subnitrate, unguentum resinse, or a benzoated oxide- 
of-zinc ointment containing 5 or 10 per cent, of carbolic acid. 
When from irritating vaginal discharges, the applications may 
be used with antiseptic vaginal douches and vulval washes, 
such as 1 : 2000 aqueous solution of mercuric bichloride or 2 per 
cent, carbolic acid. Skene highly recommends a 1 : 500 solution 
of the bichloride in emulsion of bitter almonds. When due to 
venous congestion, astringents act beneficially, such as lead, in 
washes and in vaginal douches, a 1 or 2 per cent, solution of 
nitrate of silver in water, or the oxide-of-zinc powder, strong or 
diluted with an equal quantity of chalk. General debility, gastro- 
intestinal derangements, uncleanliness, and the like should be at- 
tended to faithfully. To relieve the itching many remedies have been 
used. The benzoated oxide-of-zinc ointment, with the addition of 
10 per cent, carbolic acid or 5 per cent, of menthol, is useful. A 
10 per cent, emulsion of chloroform in olive oil or a 5 per cent, 
aqueous solution of cocaine gives temporary relief. Cold-water 
applications stop the itching when other remedies fail. The treatment 
is of necessity often empirical. Many patients suffer continuously 
for years without obtaining relief. Under the most favorable cir- 



162 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

circumstances a cure is difficult and is only obtained by persistent 
attention to the details of treatment. Cleanliness, dryness, and 
a minimum amount of friction add materially to the desired result. 

Specific Diseases of the Vulva. 

Gonorrheal Vulvitis is an inflammation of the vulva caused by 
the specific germ of gonorrhea, and may be considered as a part of 
specific or gonorrheal vaginitis. 

Syphilitic Affections of the Vulva occur in the form of chancres, 
mucus-patches, and syphilitic skin eruptions. The chancre has a 
dark-red surface, is sharply defined, is not excavated, is not tender 
or itchy, is single, with a hard base, and presents firm resistance 




Simple Vegetations of the Vulva. 

to the fingers grasping it from the sides. Inguinal glands are ordi- 
narily enlarged without much tenderness. 

The ulcerations or eruptions following vulvitis are itchy, tender, 
somewhat excavated, and have not a firm base, except in connection 
with surrounding infiltration. Mucus-patches, gummata, and the 
skin eruptions exist in connection with other manifestations of 
syphilis, and have the same characteristics as those occurring else- 
where. The inguinal glands may be tender, but do not become 



DISEASES OF THE VULVA AND VAGINA. 



163 



greatly enlarged. A chancre may ulcerate at its centre, but pre- 
serves its characteristics at the edges. 

The Chancroid is multiple, has sharply-defined edges, suppurates 
freely, has a soft yellowish or greenish fissured base, and is usually 
accompanied by a large, tender inguinal gland, with tendency to 
suppuration. The sharp edges and yellowish or greenish base dis- 
tinguish it from other ulcerations or eruptions. It should be treated 
by cauterization, iodoform, and frequent antiseptic lotions. 

Venereal Warts are the result of venereal or unclean genital dis- 
charges. They consist in irregular masses of papillomata about the 
anus or vulva. Vaginal douches of 1 : 2000 bichloride of mercury, 
frequent washings with the same, the constant application of the 
oxide-of-zinc ointment with 10 per cent, carbolic acid, or of resin 
cerate, will occasionally result in a cure. Cauterization with nitro- 
muriatic acid is usually effective. When much elevated above the 
surface of the skin (condylomata), they should be cut off and the 
base cauterized. 

Injuries of the Vulva. 
Injuries to the external genitals in women and children from 
blows, falls from elevated places upon the end of stakes, pitchforks, 
backs of chairs, fences, etc. sometimes prove serious from the hem- 
orrhage that is liable to follow injury of the corpora cavernosa. 



Fig. 53. 




of the Vestibule. 



The first marital embraces, and even brutal kicks by intoxicated 
husbands, have produced extensive contusions and lacerations. 



164 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

Contusions should be treated as those occurring elsewhere in the 
cutaneous tissue. Lacerations should be sutured with deep stitches, 
so as to close up all deep veins, and thus prevent extravasations of 
blood and subsequent abscess. 

Hematoma of the Vulva. 

Hematoma of the vulva occurs in the puerperal state as the 
result of the pressure of the head during labor, or in the non- 
puerperal state, from blows or fine punctures, producing a lesion 
of a vein in the corpus cavernosus. It is usually unilateral. 

When found after labor it may be as large as the fist or larger, 
but is seldom half as large under other circumstances. It is felt as 
an elastic globular tumor in the labium, without much heat or ten- 
derness, and unaffected by coughing or increased intra-abdominal 
pressure made by the patient. Often the first sign is a feeling of 
discomfort in the part, and the accidental discovery by the patient 
of the enlargement. In other cases a sudden burning pain is 
felt, followed by a feeling of tension and a desire to urinate or 
defecate. 

The hematoma is either gradually absorbed, remains for a long 
time encysted, or undergoes the suppurative process. 

An hematoma larger than a walnut, detected as soon as, or before 
the bleeding has stopped, is best treated by an incision between the 
labium majus and minus, a clearing out and disinfection of the 
cavity, and suturing so as to include the vessels and close the 
wound completely. A small effusion may be treated by the appli- 
cation of an ice-bag in the hope of preventing an increase. After 
the hematoma has formed and shows no sign of growing larger, it 
may be let alone with the expectation that it will be absorbed. 
When it has become encysted the patient may choose between hav- 
ing the cyst excised or waiting for a tedious length of time for slow 
absorption. To incise, evacuate, and pack the cyst with gauze, 
usually means a slowly-contracting cavity or an abscess ; hence it is 
always well to enucleate or dissect out the cyst-wall and close the 
wound completely with deep sutures. After suppuration has com- 
menced the abscess should be opened without delay, and, if possible, 
the abscess-wall excised and the wound sutured with antiseptic pre- 
cautions. When the facilities for such treatment are wanting, 
incision, disinfection, and packing with gauze is the next best pro- 
cedure. 



DISEASES OF THE VULVA AND VAGINA. 165 

Varicose Veins of the Vulva may be caused by pressure upon the 
pelvic veins by the pregnant uterus, intra-pelvic tumors or accumu- 
lations, or, in those predisposed to it, particularly in hot climates, 
by constipation, straiuing at stool, or occupations requiring constant 
standing with the exertion of intra-abdominal pressure. 

During pregnancy they may form a swelling as large as the fist, 
and may rupture during labor, causing a large hematoma. 

In the non-puerperal state they cause a slight swelling of one 
or of both labia, or can be seen on their inner surfaces, often ex- 
tending into the pelvis. 

They either give rise to no trouble or produce a feeling of burn- 
ning, an itching or fulness, with perhaps a slight desire to urinate. 

Astringent washes, vulval pads under a T-bandage, rest in the 
recumbent position for a few hours each day, and the avoidance of 
standing, leaning over and lifting, are helpful. The bowels should 
be well regulated, and the general nutrition and vigor of the patient 
promoted by tonics, massage, moderate exercise, fatty foods, etc. 

When a varicose vein ruptures compression will usually control 
the hemorrhage temporarily, but, as it is pretty sure to return after 
the pressure is removed, the ligature should be resorted to. 

Hydrocele of the Labium Majus. 

Hydrocele in the female is a rare affection, and usually consists 
in a prolongation of the peritoneal pouch (canal of Nuck) along 
the round ligament, through the inguinal canal, to the mons Veneris 
and into the tissues of the labium majus. Usually the sac closes 
by adhesion of the peritoneal surfaces at the internal abdominal 
ring. The labium, particularly the upper part, is enlarged, as in the 
case of hernia, but with less fulness at the external abdominal ring. 
If the communication with the abdominal cavity be not obliterated, 
the swelling disappears when pressed, and may be felt to vary in size 
with increase or decrease of abdominal pressure (coughing, etc.). 
Usually, however, the tumor is elastic, translucent, and yields clear 
serum upon aspiration. It is not tender to moderate pressure. When 
the tumor is reducible a truss may be worn. When not reducible it 
may be aspirated. If it fills again, it should be evacuated, and 
obliterated by an injection of tincture of iodine. If this does not 
cure it, the entire sac should be dissected out and the parts sutured 
with silkworm gut. 



166 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



Pudendal Hernia. 

Pudendal Hernia (hernia labialis inguinalis) corresponds to 
scrotal hernia in the male. The canal of Nuck and the ingui- 
nal canal become dilated, and the intestine and peritoneum are 
forced along the round ligament to the external ring and into the 
labium majus. A rounded tumor is felt in the upper part of the 
labium, prolonged into the inguinal ring, soft, insensitive to pres- 
sure, compressible, sometimes resonant upon percussion, and usually 
disappearing entirely, with a gurgling sound, if the patient be placed 
in the knee-chest position. It is very seldom strangulated. The 
omentum, and, very rarely, the ovary may be found in the sac. 

Fig. 54. 




Hernia Labialis Inguinalis and Uterine Prolapse. 

It is differentiated from a distended vulvo-vaginal gland, in 
that the latter is well down in the labium, is tense, tender, irre- 
ducible, and cannot be traced upward. Vulval abscesses are tender 
and surrounded by indurated tissue. 

The treatment consists in a replacement and the adjustment 
of a truss with a perineal strap to pass over the labium. A descrip- 
tion of the operations for strangulated hernia and permanent closure 
of the inguinal canal belongs to works on general surgery. 

Posterior Pudendal Hernia (hernia vaginalis labialis) has been 
observed a few times. It appears in the posterior portion of the 



DISEASES OF THE VULVA AND VAGINA. 



167 



labium majus, and consists in a defect in the pelvic fascia anterior 
to the broad ligament, with descent of the contents of the abdominal 
fascia along the vagina into the labial tissues. 



Fig. 55. 




Hernia Vaginalis Lal.nalis. 



The diagnosis is made in the same way as for the ordinary 
pudendal hernia, excepting that the contents extend under the 



Fig. 56. 



*£ 



■,'Mf 




Hernia Vaginalis. Lal.iali-, extending into the Labium Major. 



pubic ramus. Stoltz was able to feel the defect in the fascia and 
levator ani through which the protrusion occurred. According to 



168 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



exjoerience, pessaries and operations are 
attached to a stem may be adjusted. 



useless. A belt with a 



Tumors of the Vulva. 

. — Elephantiasis occasionally affects the external 
genitals of the female, and exhibits the same characteristics as that 
occurring in the skin elsewhere. It usually affects the entire vulva, 
and in tropical countries has been known to form a large tumor 
hanging between the thighs. 

The diagnosis is made by the fact that the swelling affects the 
skin itself and cannot be separated from it, as in fibroma, lipoma, and 

Fig. 57. 




Elephantiasis of the Labia. 

cystoma. Venereal warts are implanted upon soft natural skin, 
while the papillary excrescences of elephantiasis grow upon thick- 
ened, indurated skin. 

Malignant tumors are accompanied by deep-seated induration, 
and more ulceration in proportion to the enlargement; they run a 



DISEASES OF THE VULVA AND VAGINA. 169 

malignant course, while elejmantiasis never kills. Lupus has 
more discoloration, deeper-seated induration, and ulcerates more 
extensively. 

The treatment consists in removal of the mass and suturing 
the wound. 

Fibroids of the Vulva occur most frequently in the labia majora, 
but have been observed in the labia minora and perineum. They 
are hard, well defined, insensitive, and movable under the skin, 
unless developed in the cutaneous connective tissue, when they 
project and even become pendulous. They may undergo cystic 
degeneration. Sometimes they become quite large and the skin 
over them ulcerates. They should be removed by the knife, as 
soon as discovered. 

Fig. 58. 




Fibroid of the Left Labium Majus. 

Vulval Cysts are usually distended glands found in the labia 
majora, and may be single or multiple, deep-seated or superficial, 
varying from the size of a pea to that of a walnut or an egg, and 
occasionally larger. They are easily recognized as elastic bodies 
that yield a serous fluid upon aspiration. Usually they enlarge in 
a downward direction. 



170 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



The best teeatment consists in the removal of the entire sac by 
dissecting it from its connective-tissue surroundings, and closure of 
the wound by deep sutures. 

Fig. 59. 




r v : £;5 



Cystic tumors of the clitoris have been met with a few times. 
They usually contain a bloody fluid. Sometimes they gradually 




Cystic Tumor of the Clitoris, containing twenty-two ounces of fluid. 



DISEASES OF THE VULVA AND VAGINA. 



171 



shrivel up, after having their contents evacuated, and at other times 
they require amputation. Sometimes they attain a moderate size, 
and then stop growing, and the patient may prefer to have nothing 
done. 



Fig. 61. 




Tumor of the Clitoris. 



Lipoma of the Vulva. 

Fatty tumors may occur in the vulval, as well as in other fatty 
tissue. Usually they are somewhat soft, and when a large size is 
attained, give a sense of fluctuation to the percussing finger. They 
are a little softer than fibroids, but the skin is somewhat hypertro- 
phied, and is apt to be contracted in spots, corresponding to depres- 
sions between the lobules of the tumor. They may resemble ele- 
phantiasis, but fluctuate more distinctly. 

Fig. 62. 




:/ 



Adipose Tumor of the Left Labium. 



172 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

The treatment consists in removal by the knife. 

Occasional cases of Neuroma, Enchondroma, Melanoma, and 
Angioma of the Vulva have been observed, but their occurrence 
is so rare that a description is here superfluous. They should be 
removed the same as if found elsewhere in the body. 

COCCYGODYNIA. 

Coccygodynia is the name given to pain in the coccyx, induced by 
motion of the part, whether from external pressure or contraction 
of the muscles attached to it. 

The disease consists usually of a local arthritis. Not infrequently 
there is a rigidity or ankylosis of the joints, with dislocation or frac- 
ture, forming an artificial joint. Necrosis sometimes results. 

Parturition in old primiparse in whom the articulations have 
become rigid, and falls or blows upon the coccyx, are the ordinary 
causes. Rheumatism may possibly produce it. The principal symp- 
tom is pain in the coccyx upon sitting down, getting up or chang- 
ing position. Any posture in which the coccyx is pressed up, or 
which calls into play its attached muscles, is intolerable. Sexual 
intercourse and straining at stool are apt to be painful. The dis- 
ease is diagnosed by taking the coccyx between the finger, intro- 
duced into the rectum, and the thumb placed between the nates, 
and moving the bone, thus bringing on the pain. 

Under certain circumstances the prognosis is favorable, although 
several months, or even years may elapse before all sensitiveness 
will subside. 

The treatment must be conducted upon the same principles 
as in a traumatic arthritis elsewhere. First, the avoidance of all 
motion of the joints or pressure upon the bone. Rest on the side, 
air-cushions to sit upon, with great care in sitting down, getting up, 
leaning over, or twisting the trunk, so as to avoid producing the 
pain, are items of prime importance. Leeching and cold applica- 
tions in the acute stage, counter-irritation and alterative applica- 
tions in the subacute and chronic stages, are beneficial. 

In neglected cases, subcutaneous tenotomy or extirpation must 
occasionally be resorted to. 

Tenotomy is performed by introducing a tenotome under the 
skin at the end of the coccyx, pushing it along the side of the 
bone, and severing the entire muscular attachment, first on one 
side and then on the other, and finally at the lower end. The 



DISEASES OF THE VULVA AND VAGINA. 173 

relief afforded is great, but often only temporary, on account of 
the reunion of the severed parts. 

Extirpation is accomplished by a longitudinal incision down to 
the bone, amputation through the second joint, and severance of the 
attachments; or the attachments may be severed first, the coccyx 
dislocated backward, and the entire bone removed. 

VuLVO-VAGINAL HYPERESTHESIA AND VAGINISMUS. 

Vulvo-vaginal Hyperesthesia consists in an extreme sensitiveness 
of a part, or of all parts, of the vulvo-vaginal entrance, except the 
labia majora. 

In some cases there is a congested appearance of the parts, or 
even inflammation and erosion ; in others there is nothing abnor- 
mal to be seen. The pathological conditions sometimes consist in 
inflammation of the inner genital organs, with or without irritating 
discharges, or in a disordered state of nutrition and enervation. 
Inflammation about the hymen or cicatricial contractions about the 
carunculse cause the most severe forms. 

The most noticeable symptom is sudden flinching or a manifes- 
tation of pain upon the least touch of the parts, although if the 
finger can be placed quietly on the hymen or in the vagina and 
left there, the complaints soon cease until some motion is made, 
when they begin again. Coitus may be excessively painful or not 
tolerated at all. Anything that alarms the patient, or even calls 
her attention to the condition, increases the difficulty. 

The treatment consists in removing all inflammatory condi- 
tions, if such exist, by the means recommended elsewhere. Sooth- 
ing or anesthetic washes or ointments, such as a 5 or 10 per cent, 
solution of cocaine, or half that strength of menthol in cerate, or 
oxide-of-zinc ointment, may be used previous to all manipulations 
and at other times when discomfort is felt. Sometimes a 5 per cent, 
solution of nitrate of silver or strong carbolic acid applied once a 
week is useful to cure erosions or ulcerations. 

A valuable means of diminishing, and sometimes of curing the 
trouble in mild cases consists in introducing a bivalve speculum two 
or three times weekly, and slowly, almost insensibly, stretching the 
vagina and vaginal entrance until decided discomfort, but not severe 
pain, is felt, and then in placing a pledget of wool in the upper part 
of the vagina and leaving it for twenty-four or thirty-six hours. The 
pledget should be small at first, but gradually increased in size until 



174 AN AMERICAN TEXT- BO OK OF GYNECOLOGY. 

the vagina is well tamponed. It is preferable to place a small cot- 
ton pledget saturated in a 50 per cent, solution of boro-glyceride 
against the cervix, and the dry wool below it, but not low enough 
to press at the vaginal entrance. An uncomfortably tight vaginal 
packing or rough or painful treatment or manipulation in the begin- 
ning might antagonize the patient and make her worse. Mildly 
stimulating and antiseptic vaginal douches, such as 2 per cent, car- 
bolic acid or 1 : 200 to 1 : 500 solutions of permagnate of potassium, 
often help to render the vulvo-vaginal nerves tolerant. A general 
tonic treatment is of great benefit in many cases. 

Vaginismus is a vulvo-vaginal hyperesthesia of an aggravated 
character, with peculiar painful spasmodic contractions of the peri- 
neal and levator ani muscles. The causes of both affections are 
similar, but small spots of erosion about the vaginal entrance or a 
diseased condition of the hymen or its remains are more frequently 
found in vaginismus. Frequently no cause whatsoever can be 
discovered. 

Fig. 63. 




Fibro-papillary Hypertrophy of the Hymen in a case of Vaginismus. 

Coitus is seldom tolerated, and the attempt causes a firm clo- 
sure of the vagina by the contraction of the constrictores cunni 
et vaginae. A vaginal examination is often impossible until the 
patient is anesthetized, when the orifice becomes relaxed. 

In mild cases the treatment given above for vulvo-vaginal 
hyperesthesia may be tried, especially the vaginal packing. Some- 
times a thorough stretching under anesthetics, with the subsequent 
daily introduction of a glass plug dilator, will effect a cure. The 
stretching can be accomplished by introducing a large bivalve spec- 
ulum, separating its blades widely, and withdrawing it quite rapidly. 



DISEASES OF THE VULVA AND VAGINA. 175 

The glass plug, which has the shape of a widened test-tube, about 
2i inches in diameter, should be worn four or five hours a clay for 
a few days, then two or three hours a day for several weeks. 

In a few cases it may become necessary to practise J. Marion 
Sims's plan of excising the hymen and cutting deeply into the con- 
strictor cunni and edge of the levator ani on either side, so as to 
completely relax the vaginal entrance. 




Vaginal Plug. 

The plug should then be worn almost constantly for a few days, 
then two or three hours daily for ten days or two weeks. Inter- 
course should not be allowed until the wounds have been for some 
time entirely healed. 

Kraurosis. 

Kraurosis represents the last stage of vulvitis. Small red spots 
and streaks appear on the labia minora, in which dilated capillaries 
can be seen. These spread in curves, and often disappear in the 
places first observed. Later the mucous membrane becomes pale, 
and shrinks progressively until in time the nymphse disappear and 
the vulva is almost closed. 

At first there is round-celled infiltration and dilation of the 
capillaries, and hypertrophy of the epithelial covering, which is 
followed by a thinning of the rete mucosum, a shrinking of the 
papillae, and disappearance of the sebaceous and sudoriferous glands. 

The symptoms are not always characteristic until the disease is 
well advanced. Pruritus, local pain, and a tendency to crack and 
bleed upon coitus or slight traumatism are the most noticeable. The 
surface is usually dry, although a slight yellowish discharge may be 
present in the beginning. The progress is slow, but steady. 

The only satisfactory treatment is excision of the parts. Appli- 
cations of strong carbolic acid have been used with temporary benefit. 

The disease has been considered as essentially the same as tra- 
choma of the eye. Good results are reported from the use of a 
spray of peroxide of hydrogen to cleanse the parts, followed by the 



176 AN A3IEBICAN TEXT-BOOK OF GYNECOLOGY. 

application of an ointment containing from 1 to 3 per cent, of the 
yellow oxide of. mercury twice weekly by means of a speculum, the 
patient to apply the ointment twice daily externally. 

Imperforate Hymen. 

As the symptoms of imperforate hymen are the same as in many 
cases of atresia of the vagina, it will be appropriate to consider both 
of the affections under the latter heading. 

Atresia of the Vagina. 

Atresia of the vagina may be congenital or acquired, and may 
involve any part or all of the vagina from the hymen to the cervix. 

Causes. — The congenital variety arises from inflammation that 
has existed before birth, causing adhesion of the mucous surfaces of 
the hymen or vagina. After birth it may be caused by septic or 
gangrenous vulvitis, or inflammation connected with diphtheria, 




Atresia of the Hymen. 

typhoid fever, scarlatina, or measles, or by destruction of the vaginal 
epithelium or walls, following the introduction of chemical or me- 
chanical agents. In such cases either adhesion of the walls or 
cicatricial contraction in the ulcerated or sloughing parts occurs. 
Sloughing after labor, resulting in circumscribed or complete loss 
of the vaginal walls, is accountable for quite a large proportion of 
cases. Non-puerperal traumatisms also enter as a causative factor. 



DISEASES OF THE VULVA AND VAGINA. 



177 



Varieties. — The places of obstruction may be low down, con- 
sisting either of an imperforate or impervious hymen, or of the 
occlusion of the lower end of the vagina. The obstruction may 
be in the middle or upper portion or in different portions of the 
viscus, or it may involve the whole canal. Ajiother variety con- 
sists in a double vagina and uterus, one side of which ends in a 
blind sac above the hymen. In many cases the condition is one of 
stenosis instead of complete obstruction. 

Fig. 66. 




Complete Occlusion of the Vagina 



Complete or extensive congenital obstruction of the vagina is 
generally found in connection with deficient development of the 
uterus and ovaries. 

Course. — Obstruction at or near the hymen may be accompanied 
by a retention of mucus in early life, and of the menstrual fluid in 
later life, particularly if the development of the uterus and ovaries 
has not been interfered with. The vagina becomes dilated and 
hypertrophied, and sometimes also the cervix, uterus, and Fallo- 



178 ^LV AMERICAN TEXT-BOOK OF GYNECOLOGY. 

pian tubes. These latter are more often dilated when the atresia 
involves the upper portion of the vagina, and in such cases pelvic 
peritonitis often ensues with adhesions, and occasionally rupture of 
the tubes. 

When there is occlusion of the lower end of one side of a dou- 
ble vagina and uterus, the occluded side is most liable to burst 
into the other side, particularly through the cervical septum. The 
tissues then become infected, and develop into a pyokolpos or pyo- 
metra. The dilated Fallopian tube has also been observed to 
burst into the peritoneal cavity. 

Symptoms. — The deformity may be discovered in early life, but 
the symptoms do not usually appear until after puberty. Amen- 
orrhea is, as a rule, the first. Recurrent menstrual pains are felt 
each month, but attention may not be called to the condition until 
the patient marries and finds copulation to be impossible. After con- 
siderable accumulation has taken place, pressure upon the bladder 
or rectum may cause pain in these organs and interfere with their 
normal action. Later, the symptoms of pelvic peritonitis, pelvic 
hematocele, or septicemia may be added, in connection with the 
development of hematosalpinx, and rupture of the uterus or tube, 
or of pyometra and pyosalpinx. 

Diagnosis in Case of Imperforate Hymen. — Physical exam- 
ination reveals an absence of the vaginal entrance and the presence 
of an elastic swelling under the pubic arch, which sooner or later 
can be detected over the pubes. Obscure fluctuation or a feeling 
of elastic continuity is then recognized if one hand be placed over 
the pubes and another upon the swelling below, whether from its 
vulval aspect or by rectal indigitation. The finger in the rectum 
recognizes an elastic globular tumor partially or completely filling 
the pelvis. A catheter in the urethra passes in front of the mass. 
There is but little tenderness of the parts except at the time of 
the menstrual pains. 

Stenosis, or incomplete obstruction, is known by the fact that an 
occasional escape of the menstrual fluid occurs. A careful exam- 
ination, particularly under an anesthetic, will usually lead to the 
discovery of a small opening. The opening is sometimes found 
just under the urethra, pointing upward, and is most easily located 
by means of a fine bent probe. 

Congenital atresia is nearly always discovered at or near puberty, 
if not earlier. The acquired forms often show some irregular con- 



DISEASES OF THE VULVA AND VAGINA. 



179 



tractions or cicatrices due to past inflammation. Cicatrices are 
made more noticable by hooking a finger in the anus and putting 
the perineum on the stretch. 



Fig. 67 




Hypertrophied Vaginal Walls above an Atresia of the Vagina. 

Occlusion of the lower end of the vagina gives rise to the supra- 
pubic tumor, but is not accompanied by the elastic vulval swelling. 
The finger in the rectum and the sound in the bladder enable us 
to feel just how far down toward the vulva the retention tumor 
reaches. When the whole vagina is occluded the bimanual rectal 
examination discovers the enlargement to be uterine and the vagina 
to be collapsed or in the form of a fibrous cord. When the occlu- 
sion is in the upper part of the vagina, its upper end is discovered 
by the same bimanual examination, and the lower end by the finger, 
or sound in the vagina introduced while the finger is still in the 
rectum. 

On account of the uterine enlargement it is difficult to recognize 
the dilated tubes, although an anesthetic will sometimes enable us 
to do so. 

Occlusion of one side of a double vagina is not accompanied by 
amenorrhea. The other symptoms, as well as the signs obtained 
by rectal and abdominal examination, are much the same as in 



180 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



cases of single vagina. The finger in the vagina, however, dis- 
covers a rounded tumor projecting into it from one side, and so 
flattening the cervix as to render the os somewhat crescentic in 
shape, with the concavity toward the affected side. If the 
tumor be aspirated from the vagina, a tarry fluid will be with- 
drawn, proving its nature. "When there has been a perforation in 
the cervical region, pyokolpos and pyometra will usually have 
resulted. The tumor is less firm, and pressure upon it generally 
causes pus to flow into and out of the vagina. There will be septic 
symptoms, with occasional discharges of pus per vaginam, giving 

Fig. 68. 




Septate Uterus and Double Vagina, with Retention of Menstrual Fluid on the Left Side. 

temporary relief. If rupture of the septum does not occur, the 
mass may finally project through the vulva and give the appear- 
ance of a prolapse of the vagina or a cyst of the vaginal wall. 

Prognosis. — Without interference the prognosis is, as a rule, 
bad. Dilatation of the uterus and Fallopian tubes, with pelvic 
peritonitis and adhesions, and occasionally rupture of the Fal- 
lopian tubes, pelvic hematocele, and even death, follow. Distor- 
tion of the organs concerned, with permanent destruction of their 
functions, is the rule when interference is delayed. Bursting exter- 
nally, excepting in the cases of double vagina, seldom occurs, and 
even then only after irremediable damage is done to the organs of 
procreation. 

Treatment. — The only rational treatment consists in evacuation 
of the fluid, and this should be done as early as possible after its 
discovery. The danger connected with the operation is threefold — 
viz. (1) danger of intraperitoneal rupture of a dilated and adherent 
Fallopian tube, as the vagina contracts; (2) of sepsis due to infee- 



DISEASES OF THE VULVA AND VAGINA. 181 

tion of the contents through the opening made; and (3) of injury 
of the bladder and rectum during the operation. 

In cases of occlusion at or near the hymen, in which the accumu- 
lation is only recent, the second danger — viz. sepsis — is the only one 
to be feared. When the accumulation is of long standing and forms 
a large suprapubic tumor, the first danger — viz. rupture of a Fal- 
lopian tube — is to be guarded against. The best way is to make a 
small opening into the mass and allow the contents to flow away 
gradually, taking from one to two or three hours ; then to enlarge 
the opening by a crucial incision and wash out the sac with a great 
quantity of sterilized saline solution (i of 1 per cent.), and j)ack 
the vagina loosely with iodoform gauze. In no instance should a 
long time elapse between opening and cleaning out, for fear of 
serious or fatal septicemia. Aseptic and antiseptic precautions must 
be observed throughout. 

The gauze should be removed in twenty-four hours, and the cav- 
ity thoroughly washed out with a mild antiseptic solution, such as a 
1 per cent, carbolic-acid solution, twice daily. The tendency to con- 
traction of the opening may be combated by having the patient wear 
a glass plug part of the time. 

When the atresia is higher up in the vagina, all three of the 
dangers above mentioned are to be guarded against. It is necessary to 
dissect with the scalpel and finger, using the latter as much as possi- 
ble between the bladder and rectum toward the tumor. A finger 
should be kept in the rectum as much of the time as possible for a 
guide, and the bladder held out of the way by a catheter or sound. 
As soon as the tumor is felt through the new opening, a trocar should 
be pushed into it, and the contents allowed to ooze out very slowly, 
the opening being then enlarged by small cuts with a probe-pointed 
bistoury and moderate stretching with the finger. 

Puncture through the rectum or bladder may be resorted to 
when it is impossible to operate safely by way of the vagina, but 
these are makeshift methods attended with danger from sepsis, and 
should be resorted to only in case of absolute necessity. They are, 
however, preferable to a let-alone policy. 

Retention in one side of a double vagina should be treated on 
the same principles as the varieties already mentioned. The evacu- 
ation should be provided for through the vaginal septum. Excision 
of a portion or all of the septum is the surest way of* effecting a 
complete cure. 



182 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

Vaginitis. 

The vaginal membrane partakes more of the character of skin 
than of mucous membrane. On account of its protected situation 
the horny layer is not well developed, except in some cases in which 
the membrane protrudes continuously through the vulva. At the 
upper end, however, it partakes a little more of the character of 
mucous membrane, in that it here contains a few muciparous glands. 
This dermoid character enables it, in its normal state, to resist infec- 
tion by the various pathogenic bacteria that enter it. 

Etiology. — Any influence, however, which injures the vaginal 
epithelium, such as the long-continued friction of foreign bodies or 
chemically irritating secretions or injecta, diminishes or annihilates 
this resisting power. If accompanied by a lack of drainage and 
consequent accumulation of secretions, the microbes multiply, infec- 
tion follows, and vaginitis finally results. 

Irritation, instead of exciting inflammation, merely leads to an 
increase in the density of the epithelium, with increased resisting 
power, as is the case with cutaneous irritation. Even a local loss 
of epithelium is not accompanied by an extension of the inflam- 
mation, provided the secretions find a ready outlet or are kept 
washed out. 

Disordered states of the general system, such as anemia, chloro- 
sis, indigestion, constipation, and conditions which tend to produce 
unhealthy conditions of the skin, predispose to vaginitis. Preg- 
nancy, abdominal tumors, and any condition that produces pelvic 
congestion, whether venous or arterial, may also be considered as 
predisposing causes, and are to be taken into account in the treat- 
ment. Pregnancy acts both by producing venous congestion and 
oedema and by increasing the activity of the secretions. Secretions 
retained by a tight hymen may become infected and overcome the 
resistance of the pavement epithelium. Pin-worms, masturbation, 
and other causes of uncleanliness may have a similar effect. Patho- 
genic secretions from the uterus, urethra, vulva, or introduced from 
without are frequent causes. Gonorrheal pus is undoubtedly the 
most common cause in adults. That the vagina of the adult may 
become infected it is necessary that the epithelium have suffered 
injury or that stagnant secretions remain in contact a long time. In 
children and old people infection takes place more easily. Inflam- 
matory action and infection may also be spread by contiguity of 
surface from the cervix or vulva. 



DISEASES OF THE VULVA AND VAGINA. 



183 



The exanthemata are held accountable for a small share of the cases. 

Varieties. — Vaginitis may conveniently be considered under 
the following heads : Simple, Gonorrheal, Granular, Adhesive, 
Emphysematous, Vesicular, and Cystic. 

Fig. 69. 




Simple Vaginitis. 

Pathology. — Simple and Gonorrheal Vaginitis in the acute 
form present the following changes : hyperemia, with redness, 
dryness, and swelling of the papillae; serous secretion, rapidly 
becoming purulent ; small-celled infiltration of the epithelial struc- 
ture ; and some shedding of epithelial cells. If the disease lasts for 
some time, the deeper layers may become infiltrated, with loss of 
epithelium in places. In the beginning the changes may be con- 
fined to isolated spots. When caused by chemical irritants, such as 

Fig. 70. 




strong solutions of iodine, a sort of vesication may occur, with 
exfoliation of large layers of epithelial tissue looking like false 
membrane. As the vaginal epithelium has the power of resisting 
the invasion of the gonococcus, gonorrheal vaginitis is a compara- 
tively rare affection in adults. 

In the severer cases, and particularly acute attacks engrafted 



184 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



upon chronic inflammation, in the hyperemia dependent upon preg- 
nancy, or other disturbing influences, the papillae undergo the same 
changes, but to a greater degree. The epithelium is exfoliated, and 
the enlarged papillae resemble a mass of granulations, giving rise to 
the name Granular Vaginitis. 

In children and in old people, in whom the papillae are smaller 
and the epithelial layer thinner, the inflammation is usually found 
more in patches, the secretion scanty, the surface smoother, and 
often ecchymotic in spots. The epithelium is shed in places and 
the surfaces may be glued together. We then have Adhesive 
Vaginitis. 




Adhesive Vaginitis. 

Emphysematous Vaginitis is an inflammation of the vagina 
attended with development of gas in small spaces and canals of the 
connective tissue and lymphatics at the upper end of the vagina, 
and usually in pregnant women. They project like little bladders 
on a raised hyperemic base, and collapse when punctured. Desqua- 
mation or ulceration may result. 




Emphysematous Vaginitis. 

In Vesicular Vaginitis round vesicles form over the inflamed 
areas, and after bursting leave sharply -defined raw surfaces about 
the size of a split pea. 



DISEASES OF THE VULVA AND VAGINA. 185 

Follicular Vaginitis, consisting in enlarged inflamed follicles 
about the vaginal fornices, where the membranes may be supposed 
to possess more the character of a mucous membrane than lower 
down, is said to occur occasionally during pregnancy and in middle 
and advanced age. Whether the little nodules observed are really 
enlarged follicles or not is still a matter of controversy. 

The older authors describe vaginitis as an inflammation of a 
mucous membrane, but the tendency now is to look upon it as 
more of the nature of a dermatitis, and thus some confusion as 
to nomenclature still exists. 

Symptoms. — In acute vaginitis the patient complains of a burn- 
ing pain in the vagina, usually a frequent desire to urinate, with 
dysuria, and more or less itching and burning pain about the 
vaginal entrance. There is also a feeling of heaviness about the 
pelvis, backache, and a very slight rise of temperature. A general 
feeling of malaise, a loss of appetite, and perhaps nausea, are some- 
times noticed ; sometimes irritability and indications of hysteria, 
and sometimes no general symptoms whatever. 

In the beginning there is a dryness of the parts, followed in a 
few hours by a sero-purulent discharge which tends to produce irri- 
tation externally. 

In chronic cases the symptoms are similar, although less pro- 
nounced, and may be absent altogether. 

Diagnosis. — Upon inspection the vagina is found to be swollen 
and deeply reddened, either throughout or in spots, and presents 
the characteristics described in the paragraph upon the pathology. 
The discharge is white, pale green, or yellowish, and abundant, and 
may be thick and slimy in character from admixture with cervical 
mucus. 

Prognosis. — When promptly treated, the prognosis is decidedly 
favorable. When neglected, the consequences, particularly in the 
septic forms, are often serious. It may become chronic, result in 
ulceration, adhesion, cicatricial contraction, or spread to the uterus, 
Fallopian tubes, ovaries, and peritoneum. 

Treatment. — The indications in the treatment of acute vaginitis 
are to avoid and to relieve irritation, and to secure cleanliness. 
The patient should be kept quiet (not necessarily in bed), somewhat 
restricted as to diet, and the stools kept soluble. Walking, sexual 
intercourse, and scratching the genitalia must be interdicted. 

The ffreat source of irritation is found in the infective matter and 



186 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

the character of the discharges. These must be removed as com- 
pletely as possible from contact with the vaginal membrane. Constant 
irrigation of the vagina would accomplish this, and, but for the 
trouble and irritation attending its use, would be recommended 
with the expectation of curing the case (if treated in the begin- 
ning) in from two to six days. A copious vaginal douche, con- 
tinued for fifteen minutes, of a hot (J of 1 per cent.) saline solution 
or saturated solution of boraeic acid, used in the recumbent position 
every two hours by day and every four hours by night, answers 
equally well, except that it may take longer to accomplish the 
desired result. It should be kept up in this way for a week, and 
used four times a day and once at night for another week or until 
a cure is obtained. If the disease has lasted several days, as 
is often the case, before the treatment is commenced, a mild anti- 
septic or astringent douche may be required during the second 
and third week, such as 1 : 3000 solution of mercuric bichloride,, a 
£ of 1 per cent, solution of acetate of lead, sulphate of zinc, or car- 
bolic acid. If the disease shows a tendency to become chronic, the 
strength of the solution may be doubled. In no instance should 
an astringent vaginal injection be used during the first few days of 
acute vaginitis. 

In cases in which so much douching is not well tolerated or is 
not available, the disease can rapidly be cured by the dry pack, 
used as follows : The vagina is first thoroughly douched out with 
the saline solution. Then the patient is put on the left side, a 
Sims speculum is introduced, and the cervix and vagina thoroughly 
swabbed out with a 1 : 2000 solution of mercuric bichloride and 
thoroughly dried with absorbent cotton. If the vagina be exces- 
sively tender, the bichloride solution need not be used, for it is 
necessary to avoid irritation. After drying out the parts the 
vagina should loosely be packed with sterilized plain or borated 
absorbent cotton, packing first the fornices and then the lower 
parts of the canal as the speculum is withdrawn. A dry absorbent 
dressing should be worn over the vulva and changed by the patient 
every two hours. The douching, disinfection, and packing should 
be repeated morning, noon, and night for the first two or three 
days, and after that twice a day for a week. As a precaution 
against return, a 1 per cent, carbolic-acid douche, or, if not 
well borne, the saline or boracic-acid solution, should be used every 
eight hours for a week or two longer. Attention should be given 



DISEASES OF THE VULVA AND VAGINA. 187 

to septic urethral or cervical discharges, or the vagina may con- 
stantly become reinfected. 

Rectal suppositories or medication should carefully be avoided, 
as there is danger of infecting the bowel. In case such infection 
occurs, the rectum should be washed out thoroughly every three 
or four hours with the saline solution by means of a return tube. 
Forcible dilatation of the sphincter ani adds to the efficiency 
of the treatment. The bowels should be moved once or twice 
daily by salines. 

Morphia with atropia, or chloral may be required in nervous 
patients to secure quiet and sleep at night. 

In chronic cases attention should be given to general conditions 
that might favor the local irritation, to external sources of irrita- 
tion, and especially to conditions that favor pelvic congestion, 
whether they lie within the body or in the habits and external 
surroundings. 

Large antiseptic douches, such as 1 : 2000 bichloride of mercury, 
should be used two or three times daily. Every four to six days 
the vaginal fornices may be swabbed out with a 2 per cent, solution 
of nitrate of silver or the undiluted tincture of iron, and a loose 
vaginal tampon covered with vaseline left for twenty-four hours. 
Treatment by dry powders, such as equal parts of subnitrate of 
bismuth and prepared chalk, or of tannin and iodoform, kept in 
place by a cotton tampon, is used by some gynecologists. The pow- 
der should be renewed every day, having the tampon removed and 
the old powder thoroughly douched out just before the treatment. 

In the senile and vesicular forms mild antiseptic douches are 
indicated, supplemented by strips of lint soaked in 5 per cent, 
carbolized oil or glycerin or smeared with 5 per cent, carbolized 
oxide-of-zinc ointment, or, in sensitive cases, of cold cream or almond 
oil kept in the vagina. 

In giving douches for vaginitis it should be remembered that 
there are many folds and irregularities that hide and retain the 
secretions; hence it is well to have the patient lie on the back 
with the hips elevated on the bed-pan, so that the vagina will be 
well filled. The bag of the fountain syringe should be consider- 
ably higher than the patient and the nozzle introduced well up 
toward the fornices. Tampons are best placed with the patient in 
the knee-chest position. 

Cystic vaginitis is best treated by puncture of the small cysts 



188 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

about the cervix, and the application, after their evacuation, of the 
tincture of iodine. A vaginal douche of a 1 : 2000 solution of 
mercuric bichloride should be used twice daily. 

In hospital practice, where there is always some one in attend- 
ance to give the douche, a bulb is preferable to a fountain syringe 
because the water can be pumped into the vagina with more force, 
and thus dislodges the secretions better. 

Neoplasms of the Vagina. 

Vaginal Cysts. — Vaginal cysts, excluding cystic vaginitis, are 
sacs of fluid contained in or just beneath the vaginal wall, varying 
from the size of a marble to an egg, although if not interfered with 
they may attain a much larger size. The fluid is usually thin and 
transparent, but occasionally slightly viscid and turbid. The cyst- 
wall is intimately connected with the surrounding tissues and usually 
lined with cylindrical epithelium. Pavement epithelium has been 
found in a few cases. The cysts may be situated in any part of 
the vagina and occasionally assume a polypoid character. 

Recent investigators attribute them to an embryonal origin. 
Accumulations of fluid in the partly-obliterated canals of Gaert- 
ner or ducts of Miiller, particularly the former, are supposed to 
produce them. 

They give rise to but few symptoms until they have attained 
sufficient size to press upon the vaginal entrance and cause a sense 
of discomfort and pressure, and perhaps some leucorrhea. They 
may then assume the appearance of a prolapse of the vaginal wall. 
Where a prolapse is in process of formation, a vaginal cyst may go 
far toward determining the result. 

The diagnosis is easy. When on the lateral vaginal walls, 
they are felt as hard elastic bodies that yield a thin transparent 
fluid upon aspiration. When situated upon the anterior wall, they 
may be recognized by putting a sound in the bladder and a finger 
in the vagina ; or when on the posterior vaginal wall, by the fore- 
finger in the rectum and the thumb in the vagina. 

The treatment consists in excising a part or the whole of the 
cyst-wall. When situated low down, they can easily be dissected 
out of their bed and the wound sewed up with buried catgut sutures. 
When situated higher up and complete excision is impossible, a 
port ion of the cyst-wall should be excised, the remains painted 
with tincture of iodine, and packed with iodoform gauze. 



DISEASES OF THE VULVA AND VAGINA. 189 

Fibroid Tumors of the Vagina. — Fibrous and myomatous tumors 
seldom grow from the vaginal walls. True fibro-myomas, however, 
are not infrequently met with. They may be situated in the vagi- 
nal walls the same as vaginal cysts and of the same size, or they 
may become pediculated. They present the same symptoms and 
feel much the same as the cysts, except that they are not as elastic, 
and they do not yield fluid to the aspirating needle. As they grow 
larger the surface may ulcerate, or as a polypoid fibroid is extruded 
from the vulva the capsule may undergo necrosis. Sometimes they 
are quite oedematous and soft. 







The polypoid growths may simply be cut off and the pedicle 
ligatured if necessary. The intramural tumors should be enu- 
cleated and the bed sewed up, as after excision of a vaginal cyst. 

Papillary Excrescences. 

Small papillary growths of non-malignant character are some- 
times found on the inflamed vaginal mucous membrane. They 
consist of a proliferation of connective tissue and epithelium. They 
are insensitive, but give rise to an irritating and somewhat offensive 
discharge. Sometimes they bleed quite profusely. 

They should be obliterated by a strong astringent or caustic appli- 
cation and the vaginitis treated by the ordinary remedies. 



INFLAMMATORY DISEASES OF THE UTERUS. 



Anatomy. — It is essential to a proper understanding of the 
various forms of endometritis that a short description of the anat- 
omy of the endometrium be given. The internal os fairly well 
divides the lining membrane of the uterus into two very different 
and dissimilar portions. The corporal endometrium begins here, 
lines the whole inside of the body of the organ, and extends, mod- 
ified, into the openings of the Fallopian tubes. Its characteristic 
features are these : it is firmly attached to the muscular tissue by 
a stroma of connective tissue. From this latter radiates in no cer- 
tain arrangement a fibrillar tissue, which is found in lymphoid struc- 




Fibre of the Endometrium, showing different grades of corpuscular development. 

tures only. Attached to these delicate bands and between them are 
innumerable lymphoid cells of various sizes. This arrangement 
persists throughout the membrane up to the epithelial covering. 
This covering is of cylindrical cells, ciliated, but one layer in thick- 



INFLAMMATORY DISEASES OF THE UTERUS. 



191 



ness, and lines the utricular glands. These latter are merely deep 
depressions, with perhaps branches dipping down into the lymphoid 
tissue. (See Fig. 28.) There are also lymph-spaces in the mucosa. 
They extend from the mucosa to the spaces betvyeen the bundles of 
muscular fibres. The lymph-vessels are most abundant in the ex- 
ternal muscular layer, are connected with the lymph-vessels of the 
mucosa and serosa, and run into large canals at the side of the uterus. 
The serosa has lymph-vessels only, arranged in a network, and, while 
less numerous than those in the subserous tissue, they are much 
larger. Thus the lymph passes from the mucous membrane lymph- 
spaces into the spaces and vessels of the muscularis, surrounds all 
the muscular bundles here, up to the serous coat, and then passes 
into large tubes in the broad ligaments. The uterine mucosa is, 
then, either an open lymphatic gland or a lymphatic surface inter- 
sected by blood-vessels, the lymphatics being not mere vessels, but 
spaces between the bundles of connective tissue. 




Lymphatics of the Uterus: 1. lymphatics from the body and fundus of the uterus; 2, ovary ; 3, wigina 
4, Fallopian tube; 5, lymphatics from the cervix; 6, lymphatic vessels trnin the cervix wing to tue 
iliac ganglia; 7, lymphatic vessels iivni the body and fundus uning to the lumbar ganglia; ^, anasto- 
mosis of eervieal'and uterine vessels; H, small lymphatic vessel in the round ligament going M 
inguinal glands ; 10, 11, lymphatic vessels of the tubes which empty into the large lynipna 
from the body of the uterus ; 12, ovarian ligament. 



vessels 



The mucous membrane of the cervix is dense, hard, free from 
lymphoid elements, and is a true mucous membrane. It rests on a 



192 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

submucous structure of connective tissue. The glands are numerous 
and of the compound racemose type. The membrane is thrown 
into interlacing folds {arbor vitce), and is covered by a columnar 
epithelium, in places ciliated, but on its vaginal aspect the covering 



e*%* 







Fig. 



'£ 1 



Normal Mnci.us Membrane of the Cervix. The mucous membrane of the Cervix is very firm and presents 
a number of branching folds (arbor vita). The interglandular tissue, which has, in the body of the 
organ, the nature of granulation tissue, is here of a connective-tissue type, the fusiform and stellate 
cells predominating. There is not the same clear limit between membrane and muscular coat: one 
can follow the glands deeply inward, among the connective-tissue bands, which separate the mus- 
cular bundles. Consequently the mucous membrane in section has a partly reticulated, partly fascic- 
ulated appearance. The cervical membrane possesses, moreover, many vascular papilla;. Cylindrical 
ciliated epithelium invests the glands in the adult, and in the child extends to the external os. In 
the adult, especially after pregnancy, the flat vaginal epithelium rises higher and lies more or less 
within the cervix. 'Between the superficial cylindrical epithelium and the glands, cup-shaped and 
colloid cells are here and there present. The vessels pass into the mucous membrane perpendicularly 
and have very thick walls, dividing progressively into a capillary plexus, which is less developed 
than in the body. Sometimes the capillaries lie very superficially under the epithelium, reuniting to- 
form veins, which at once leave the mucous membrane. The glands and ovula Nabothi are sur- 
rounded by the vessels. 

is of squamous epithelium. The lymphatics of the cervix are not 
so numerous as in the body, and do not enter the broad ligaments, 
but, joined by those from the upper part of the vagina, pass back- 
ward to the iliac glands and those in the obturator space. 

Physiology. — A certain force, the origin of which is not known, 
operating through the vaso-motor nervous system, causes periodically 
an increased flow of blood to the uterus, producing thereby a wonder- 
ful series of changes. These consist of a great increase in the num- 
ber of lymphoid elements in the mucosa, exfoliation of the epithe- 
lium covering the membrane and part of that lining the follicles, 
and rupture of the capillaries. Thus is produced the menstrual 
flow. The circulatory pressure subsides, the capillaries heal, a new 
epithelial covering to the surface and glands is produced, and the ex- 
cess of lymphoid cells is absorbed, this repair and waste occurring once 
in the month. There is no exfoliation of the mucosa, and the above 
changes are limited to the corporeal endometrium. The follicles of 



INFLAMMATORY DISEASES OF THE UTERUS. 193 

the uterus secrete a more or less milky fluid, somewhat viscid, alka- 
line in reaction, and free from pathogenic germs. Normally this 
secretion from the utricular follicles is so slight as not to be notice- 
able. The uterine secretion contains germs of no kind. It is simi- 
lar in this respect to the gastric secretions. The glands of the 
cervix secrete in abundance a tenacious mucus. Germs are con- 
stantly present in the cervix. The cervix is solely for the pur- 
pose of acting as a sphincter to the uterine muscle, and its mem- 
brane is not involved in the menstrual act. Its secretion is clear, 
like white of egg, very tenacious, and abundant. 

Fig. 77. 






9 M 



*h 




Transverse Section through the Upper Part of the Cervix, showing the Entire Mucous Membrane. The 
Central Cavity is the cervical canal : b, b. Internal Surface of mucous membrane, presenting small 
folds, superficial glandular depressions, and large incisions of the arbor vit« (d) ; g, g, deep glands; 
a, a, ovules of Naboth ; m, m, muscular tissue of the uterine wall. 

The endometrium is solely for the purpose of forming the decidua. 

Menstruation is merely that, periodically, the uterus gets into 
a condition more propitious for conception than at other times. The 
menstrual blood escapes, as it does in apes, because the uterine 
mucosa is of such dense character, compared to that of other ani- 
mals, that its lymph-streams are not of sufficient size to carry off 
all the products of the monthly engorgement, 

The escape of an ovule, exfoliation of the epithelium from the 
surface of the endometrium, engorgement of the endometrium with 

13 



194 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

blood, and multiplication of lymphoid cells, are the factors which 
invariably are necessary on the part of the woman, that conception 
may take place. 

The lymphoid cells produce the decidual cells, and, by them, repro- 
duction of the mucosa is brought about, after its removal ; lymphoid 
cells form also the new epithelial layer. 

In the endometrium of the child there are few corpuscles, abun- 
dant fibrillar tissue, and the follicles are mere dimples. In the 




Menstruating Endometrium of a Woman aged 20, showing Utricular Follicles denuded of Epithe- 
lium, with one still containing an Epithelial Cast. 

fully-developed woman the corpuscles crowd the tissue and are of 
all sizes. The whole membrane appears to be made of them. The 
glands branch, dip deep into the lymphoid tissue, and are lined 
with cylindrical ciliated epithelium. In old women there is 
nothing left save fibrillar tissue, a few corpuscles, and wasted 
utricular follicles. Between these extremes may be found all 
gradations, and in the same uterus at different times the arrange- 
ment and condition of vessels, epithelium, glands, and corpuscles 
so vary as to constitute essentially a different organ, under the influ- 
ence of the controlling factors, menstruation and gestation. Inflam- 
matory processes, then, imposed upon these widely dissimilar states, 
furnish a great variety of pathological appearances, and will cul- 
minate in some one of a great variety of microscopic changes. There- 



INFLAMMATORY DISEASES OF THE UTERUS. 



195 



fore, we must not expect every inflamed uterine mucosa examined 
to exhibit characteristics identical with some known standard. As 




Endometrium of a Woman aged 60, showing Exhaustion of the Whole Structure. 

the conditions under which inflammation may occur are many, so 
must be the pathological changes. 

Endometritis. 

Inflammation of the endometrium should be considered from the 
standpoint of its etiology, and, inasmuch as the treatment is largely 
governed by the causation, classification according to the latter is 
eminently proper. Therefore endometritis may be described as 
simple, septic, or specific. Descriptions of endometritis based upon 
the symptomatology and classed by authors as hemorrhagic, hyper- 
plastic, etc., are confusing, and are merely different phases of the 
same pathological condition. 

Simple Endometritis. — This is usually symptomatic and never 
acute. The membrane may be hypertrophied or atrophied. In 
the first condition the follicles are many-branched and tortuous 
with thickened epithelium, which is still deposited in one regular 
layer. The vessels are enlarged and increased in number; the 
lymph-spaces are increased in size, and the muscular walls thick- 
ened. The epithelium is easily brushed off, causing bleeding ; the 
spaces about the follicles are filled with lymphoid cells, and the 



196 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



culai 

very 



FlG - 80 - whole general aspect is one of 

ff0.) (((, ■.'",." "„•. -- increased growth and excess of 

<j;'-:0) " ".'''-',% nutrient fluid. Should there be 

'■:;:] an increase of connective tissue 
Cwni^l '^1 an( ^ accompanying glandular hy- 

pertrophy, the condition known as 
"fungoid" is produced. Here the 
fungoid elevations are cystic and 
lined by cuboiclal epithelium. 
After abortions portions of de- 
cidua may remain adherent; this 
is not a true product of inflam- 
PH mation, but rather the growth of 
$| a tissue which has partly retro- 
graded. Hypertrophic simple en- 
dometritis is usually found asso- 
ciated with those lesions which 
are pre-eminently characterized 
by a general enlargement of the 
uterus, as in retroposition, fibroid, 
subinvolution, etc.; or, glandular 
hypertrophy may occur, produc- 
ing mucus polypi. 

These polypi hang by a longer 
or shorter pedicle, and may even 
project from the cervix, although 
attached above the os internum. 
When they touch the os internum 
the cervix will be dilated and patu- 
lous, or even gaping open. 

If the membrane be atrophied, 
the follicles with their epithelial 
linings are decreased in size, the 
lymphoid tissue is not so rich in 
cells, and the whole membrane 
is below the normal in thickness. 
There is an abrupt demarcation 
, Tr.,VV^"V!i!iV,!luu,rNciV.V^Vu-tH l iis! r li>,,UI " between the mucosa and the mus- 
is, and no intermingling of these structures. There may, in 
chronic cases, be so great an increase in the connective tissue 




INFLAMMATORY DISEASES OF THE UTERUS. 



197 



as to destroy every vestige of gland-tissues, or, constricting cer- 
tain glands, cysts may be formed. This form of interstitial change 
is rare except in old women, but is very similar to alterations pro- 
duced by zinc-chloride and nitric-acid applications. Simple ante- 
flexion and non-development are the chief causative factors in 
the condition of atrophic endometritis. The blood escaping at 
the menses readily coagulates, owing to the scarcity of lymphoid 
elements; the epithelium, instead of melting off gradually, sepa- 
rates in shreds or even as a whole cast. No micro-organisms are 
found, save, occasionally, secondary tubercle bacilli. Altered circu- 

Fig. 81. 




Glandular Endometritis ; Polypoid Form. 

lation by position or flexure, and consequently perverted local 
nerve-function, are the chief elements entering into the causation 
of these two very common conditions of the endometrium. They 
can scarcely be considered as truly inflammatory, but may at any 
time become actively so. 

This glandular endometritis when forming distinct elevations or 
fungosities constitutes the condition known as " benign adenoma." 
The only adenoma from the uterine mucosa is adeno-carcinoma, or, 
in plain words, cancer. 

In all forms of inflammation of the endometrium the epithe- 
lial cells are deposited in but one regular row of single cells — 
never in layers. Beginning cancer may be differentiated by 



198 



AN AMERICAN TEXT-BOOK OE GYNECOLOGY. 



three things : the glands are not only increased in number, but are 
many times larger than the normal ; the epithelium lies in layers ; 
and the epithelial elements invade the subjacent tissues later on. 




Polyp 



Diffuse Papillary Adenoma of the Body of the Uterus with Polypi. 



Therefore, when examining curette scrapings, unless they present 
but one thickness of epithelium arranged about the glands as one 
regular layer, the case must be looked upon with suspicion. 

Symptoms. — When the membrane is hypertrophied, in addition 
to the symptoms of the causative lesion, we have certain definite ones 
due to the hypertrophy alone. The menses are increased in amount, 
sometimes painful ; the flow dark, clotted, or clear. There may also 
be intermenstrual bleedings. Bimanual examination reveals the 
gross lesion causing the condition. The sound readily produces 
bleeding, and frequently develops at the internal os a point of 
exquisite sensitiveness. The depth of the organ is increased. 



INFLAMMATORY DISEASES OF THE UTERUS. 199 

The cervical flow of mucus is tenacious and usually milky in 
character, owing to the excessive admixture of epithelium and 
lymphoid cells. There is no erosion of the cervix, and the cer- 
vical membrane is not often coincidently inflamed. Menstruation 
is followed by a more or less persistent leucorrhea. 

When the hypertrophy has gone on to the production of fun- 
gosities, increased menses, intermenstrual bleedings, and a profuse 
leucorrhea, often purulent, are the characteristic symptoms. The 
same is true when portions of decidual tissue have been retained 
and grown to the endometrium, thus forming buds and excrescences. 

With a less degree of hypertrophy the chyle-like fluid (leucor- 

Fig. 83. 



If^L 





N%# 



l 



9 9 

Section of a Glandular Uterine Polypus: a, a, superficial nodules covered with cylindrical epithelium: 
b, mouth of glands opening into a depression between ; g, deeper portions of the same glands ; v. v, 
blood-vessel. 

rhea) is non- irritating and devoid of germ-life. It is composed of 
increased secretion, fat-globules, lymphoid cells and epithelium, and 
has no odor. 

With polypi the amount of hemorrhage produced is often so 
great as to suggest fibroid ; and even a very small polypus may 
give rise to alarming floodings. The uterus always treats these 
growths as foreign bodies, the cervix remaining patulous and soft, 
and the uterine muscle making ineffectual spasmodic, attempts at 
expulsion of the growth, especially at the menses. Besides the 



200 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



intermenstrual bleedings, there may be a more or less continuous 
discharge of dark, coffee-colored fluid suggestive of malignant dis- 
ease. There can be no question that these polypoid granules, 
although in the beginning perfectly innocent, will, if allowed to 
remain for years, take on the characteristics of malignancy, in that 
their epithelial elements will invade the surrounding tissues. 
Always there is more or less of a purulent leucorrhea, due to 





Interstitial Endometritis with complete Atrophy of the Glands: A, cystic formation, last trace of the 
glands ; B, all vestige of gland-tissue disappeared. 



colonies of cocci becoming established upon the generally abraded 
surface of the polypi. The rest of the endometrium may remain 
free from the pathogenic germs. 

Often it is impossible, without intra-uterine touch, to distinguish 
polypoid endometritis from corporal cancer. The character of the 
growth determined by the microscope will enable us to differentiate 
absolutely. 

Where the membrane is atrophied the dysmenorrhea is often 
excessive. This pain precedes the flow by a few hours, is located 
just behind the symphysis, and is intermittent, alternating with the 
escape of clots. The flow is scanty or watery. There is also a 
slight leucorrhea. In both conditions there are digestive disturb- 



INFLAMMATORY DISEASES OF THE UTEHUS. 201 

ances and reflex nervous phenomena entirely disproportionate to 
the changes in the endometrium. Backache opposite the last lum- 
bar vertebra, " bearing-down" and a sense of weight more often 
accompany the hypertrophic form. Sterility results from the atro- 
phic variety more frequently, and is directly dependent upon the 
altered state of the endometrium. 

Treatment. — In no form of uterine disease is general treatment 
of so much benefit. It may even cure certain cases. Thus, a change 
of climate, the " rest-cure," and an out-door life, may determine such 
alterations in the general nutritive functions, as to relieve these 
patients of most symptoms. It is in these cases of chronic simple 
endometritis that the various springs and watering-places are of 
benefit, the general surroundings and change in mode of life accom- 
plishing the improvement, by acting through the general absorptive 
system. The small quantity of arsenic and iron in the waters has 
but little effect. The dysmenorrhea and excessive flow are lessened 
by cannabis indica, gelsemium and hydrastis. When the mucosa 
is much hypertrophied, producing fungosities or polypi, with hemor- 
rhages, the proper treatment is always to remove the entire endo- 
metrium, and, if possible, correct the lesion upon which the endo- 
metritis depends. This should be done surgically, and not by the use 
of powerful chemical agents. If the gynecic surgeon will keep 
clearly before him the fact, that there is but a little tissue between the 
endometrium and peritoneum, rich in connecting blood-vessels and 
lymph-streams, if he will view endometritis from the peritoneal 
rather than the vaginal aspect, he can make no error in choosing the 
proper method of treatment. Although the inside of the uterus, in 
these cases, is free from micro-organisms, yet they are in the vagina. 
To treat patients by zinc chloride, carbolic acid, electricity or other 
escharotics, is to produce a more or less extensive slough, retained to 
become putrid, and is to create a surface deprived of that protecting 
epithelial covering which is the organ's sole defence against the 
inroads of pathogenic germs : and they do this in an unclean 
way, with no provision for drainage. The hypertrophied mem- 
brane should be removed with the sharp curette, as will be described. 
Atrophic simple endometritis, and the hypertrophic variety when 
slight, can be relieved by removing the causative lesion and treating 
the endometrium by gauze packing. Drainage with stem pessaries, 
whether perforated or grooved, is a delusion. They do not drain, 
but are mischievous affairs, hard to keep open and clean. The 



202 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

application of mild antiseptics and astringents to the endometrium 
thus inflamed is a perfectly proper procedure, but care must be 
exercised that with the application pyogenic cocci are not intro- 
duced. If the change in the endometrium does not warrant opera- 
tive procedure, the vagina and cervix should be thoroughly cleansed, 
the cervix should be pulled down by bullet-forceps, a narrow strip 
of iodoformized gauze introduced into the uterus, and the vagina 
packed lightly with the same material. In two days this is changed 
and a larger piece of gauze introduced, the canal then being more 
patulous. When this gradual dilatation has gone so far as to ensure 
good drainage through an open canal, and there is hypertrophy of 
the uterus, intra-uterine astringents are used before introducing the 
gauze ; tincture of iodine is the preferable drug for this purpose, 
applied by means of a cotton-wrapped applicator. It is not only 
astringent, but germicidal, and is moreover not deep in its effects ;. 
its action is limited to the superficial structures only, and therefore 
produces no slough. The patient is not kept in bed, but confined 
to her room. The treatment is not painful after the first few sit- 
tings, and the endometritis is often relieved in two weeks, though it 
will recur if the causative disease be not removed. The treatment 
should be begun a week after menstruation. 

The treatment of endometritis by chloride-of-zinc pencils is still 
practised by a number of physicians in America and abroad. This 
procedure causes the exfoliation of the endometrium. It does this 
by destroying the membrane, which is cast off by suppuration, and 
a simple hypertrophic endometritis is converted into a septic pro- 
cess by its use ; at the same time a septic metritis is set up, and 
salpingitis and peritonitis may follow the treatment. The pain it 
produces is severe. Nothing could be more unscientific than this 
practice. Even though curettage were a dangerous procedure, and 
the curette often thrust through the uterus, it could not produce the 
destructive lesions which zinc does. The same objections attach to 
the use of nitric acid. Not only is the treatment itself most pain- 
ful, and prone to produce serious lesions, but it also leaves the ute- 
rus in a crippled condition. The new endometrium produced is 
atrophic, the uterus the seat of connective-tissue changes, and men- 
struation incomplete, attended by great pain due to tension, and 
hysterical manifestations. Even the chief advocates of the chlor- 
ide-of-zinc treatment admit its dangers. It is certain that those 



INFLAMMATORY DISEASES OF THE UTERUS. 203 

dangers are not to be avoided by any effort on the physician's part, 
but are inevitably inherent in the method. 

Before making an application to the uterus the entire field of 
operation should be cleansed by a solution of lysol, 1 per cent., or 
of creolin, 2 per cent., scrubbing the vagina and cervix carefully 
with cotton pledgets held by forceps. An applicator is then wrapped 
with cotton and the cervical canal wiped with either of these two 
solutions or a carbolic-acid solution, 5 per cent., care being taken 
not to invade the inside of the uterus. If a probe is to be used, it 
should be heated in an alcohol flame to sterilize. The direction of 
the cervical canal having been determined by the probe, a very fine 
fillet of iodoform gauze, 20 per cent., is laid over the applicator, 
which has been curved to the shape of the canal and is pushed up 
to the fundus of the uterus. The applicator used for this purpose 
should be so rigid as not to bend when used. The uterus should 
always be drawn down gently and steadied by means of a bullet-for- 
ceps to straighten its canal. The ordinary tenacula prick the mem- 
brane, cause pain, and are followed by the discharge of a few drops 
of blood. To avoid this, a very coarse double tenaculum, made like 
the American bullet- forceps, the points being so dull that they do 
not penetrate the mucous membrane, may be used. A wad of iodo- 
form gauze, the size of a silver dollar or larger, is then carefully 
adjusted over the cervix, and another of borated cotton is placed 
over this to retain it in place. Treated this way, no odor of iodo- 
form is noticeable about the patient, and the field of operation is 
kept aseptic from one treatment to the other. It is useless to do this 
if the patients are allowed to have intercourse or douches, or if the 
vagina is in any way invaded. After the treatment they may go 
about their rooms, and should be perfectly comfortable. It is not to 
be forgotten that the condition which causes this change in the endo- 
metrium must be cured. Polypi, fungosities, and retained decidual 
tufts are to be removed by the curette; they are not amenable to 
palliative treatment. Iodine is not of much benefit in the atrophic 
form. These latter cases often prove intractable. If they be 
subjected to the gauze packing for the three weeks preceding the 
period, and the last dressing removed three days before the menses 
come on, it will be found that the flow is increased in quantity, 
is more nearly normal in character, and the pain less severe. The 
same treatment may be repeated the next, and if necessary the suc- 
ceeding months. After the cervix has become so dilated that it 



204 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

will receive a filament of gauze half the size of a lead pencil, one 
may rest content with the result. The uterus is not to be packed, 
but the gauze is gently introduced to the fundus. The .cervix has 
the property of dilating around any foreign substance in its canal, 
and gauze packing of this size is amply sufficient to ensure good 
drainage. The results of the treatment are very satisfactory. 

Septic Endometritis. 

Septic endometritis is an infectious inflammation of the endo- 
metrium, usually caused by staphylococci, occasionally by strep- 
tococci. It may occur at any time of life and in any condition 
of the uterus, but it is most frequently seen during the menstrual 
life of the woman, being favored by that function and pregnancy. 
It may be chronic, but is most often seen as an acute affection. 
The pathology and symptoms will be modified by the condition 
of the uterus at the time of the attack. Infection of the post- 
partum uterus belongs more properly to the province of the 
obstetrician. 

Acute Septic Endometritis. — Acute septic endometritis is caused 
in the greater number of cases by infection after abortion ; cases, 
however, are caused by foul manipulations of the uterus, and 
operations upon that organ. Inasmuch as pyogenic germs are 
constant in the vagina, auto-infection is possible under certain con- 
ditions but it must be exceedingly rare. Any factor which induces 
exfoliation of the epithelium, such as menstruation, abortion, rough 
treatment, sudden congestion, exposure to cold, and the introduction 
of infected instruments into the uterus, puts that organ into a con- 
dition propitious to the development of infection. 

Pathology. — In the acute form the uterus is enlarged and 
engorged with blood. The mucosa is swollen, of a deep color, and 
the number of vessels actually increased. In spots it may be 
necrotic or the whole membrane may slough. The epithelium 
covering the membrane and lining the follicles is exfoliated to a 
greater or lesser extent, and the vessels present on the surface 
rupture, giving rise to capillary bleedings. Pus-cells cover the sur- 
face and fill the follicles; in aggravated cases they are found also in 
the lymphatics and lymphoid tissue. The muscularis is of a very 
deep color, softened and much thickened, even in a few hours. Its 
lymphatics are gorged with cocci, in advanced cases, and its blood- 
vessels with blood. True septic metritis is present. Staphylococci 



INFLAMMATORY DISEASES OF THE UTERUS. 



205 



are everywhere in the membrane, sometimes even penetrating the 
muscular walls. Rarely are streptococci found except in puerperal 
cases. 

Fig. 85. 




Puerperal Endometrium removed by Curettement on the Seventh Day : a, Necrotic layer of the decidua ; 
b, zone of reaction; c, Sections of the glands; d, Sections of the blood-vessels ;'«, Kemains of the 
glandular epithelium. 



In chronic septic endometritis the same lesions occur, only to a 
less degree. There is a general reproduction of epithelium, and the 
more acute symptom, necrosis, is absent. Pus is produced in 
quantity in the glands and on the surface of the membrane. The 
cocci may have penetrated the muscular wall, and there formed a 
pus-focus even amounting to abscess. In doing this they follow 
the lymph-streams. Complications are most likely to accompany 
these conditions, and the changes due to pelvic lymphangitis, 
ovaritis, salpingitis, and peritonitis may be found. 

Those cocci which are found present and arranged in groups are 
staphylococci, the germs always found in septic endometritis ; those 
in chains are streptococci, which cause many cases of, and are found 
in, puerperal infection. 

Symptoms. — The acute stage is often ushered in by a chill, espe- 
cially after abortion. This is followed by severe uterine colic, which 
soon becomes a continuous pain. The temperature rises to a varia- 
ble degree, with rapid pulse. In a few hours the uterus discharges 
a greenish pus or one tinged with blood. The uterine pain is 
severe, and the patient keeps the bed. Examination reveals the 
uterus enlarged and very sensitive. The pails have increased heal. 



206 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

From the cervix projects a rope of muco-pus, possibly bloody. If 
the disease has lasted a few days, the cervix is eroded, and may 

Fig. 86. 

•••;■' " * i * " ^»* 

^ c /"" "~ -• 

fei- ■'■*'>: c ' * ^ 

,-/•« •"" * j 

Cocci from an Empyema ; prepared by Gram's Method. 

even be covered by a true diphtheritic membrane, the result of 
infection by streptococci. Some of the complications which follow 
this condition may be present and add to the symptoms. The acute 
symptoms may subside in a few days, provided the very common 
complications of peritonitis and salpingitis do not overshadow the 
symptoms of the endometritis. Thus the acute form may gradually 
become chronic, with few symptoms other than a little pain, " bear- 
ing-down," and a purulent leucorrhea. It is not always easy to dis- 
criminate a chronic simple endometritis from a chronic septic one, 
but in the latter there is the invariable clinical feature of purulent 
discharge from the uterus, which is not present in the former. This 
pus does not always appear in the cervical mucus, but it can often 
be obtained with the suction syringe, and it usually follows the 
withdrawal of the sound. The symptoms of gonorrheal endome- 
tritis are very similar to those of the septic variety. In some cases 
the microscope alone will differentiate the two forms, which are fre- 
quently blended. Whenever pus escapes from the uterus, it is an 
absolute indication that pyogenic cocci are in that organ, and clinic- 
ally the case is either in a septic or specific state. 

Treatment. — The radical treatment is the best : thorough and 
complete removal of the septic focus. Curettage, irrigation and 
gauze-packing are recommended, as these uterine inflammations must 
be considered in the light of their complications. Prompt interfer- 



INFLAMMATORY DISEASES OF THE UTERUS. 207 

enee may cut short the disease, and save the patient those gross 
changes in the tubes and peritoneum which so often result from a 
neglected septic endometritis. If destructive disease of the adnexa 
has already taken place, the curettage is none the less indicated. 
The more acute the symptoms, the greater the indication for the 
operation. Some cases of chronic septic endometritis without com- 
plications may be cured without the use of the curette by the intro- 
duction of drains of iodoformized gauze, but this method must be 
pursued with the strictest attention to asepsis. The presence of a 
purulent uterine discharge j:>ositively contraindicates the use of ap- 
plications and stem pessaries, unless the applications be accompanied 
by the use of the gauze drain. The best treatment, then, applicable 
to acute and chronic septic endometritis, when complicated by disease 
of the adnexa or peritoneum, is curettage. Whether the septic 
condition follows treatment, operation, or abortion, whether it ac- 
companies cancer, polypi, fibroids, or other neoplasms, yet must the 
septic uterus be cleaned out before any other treatment is instituted. 
If infection follows plastic work on the cervix, the sutures should 
be removed, the uterus curetted and packed. 

There are so many important minor details in the after-treatment 
of septic endometritis that they require separate attention. When 
a uterus not enlarged is curetted for an uncomplicated chronic 
inflammation, the gauze need not be removed for four days, and 
renewal is not necessary. In renewing the dressings infection is 
easier than at their first application, for the reason that the uterus is 
now divested of its protecting lining. Care should therefore be 
taken not to reinfect the case. The second vaginal dressing may 
remain from three to four days and then be removed. All inter- 
ference with the vagina, in the shape of douching, coition, and 
examination, should be prohibited for the remainder of the month, 
and the patient must take to her bed on the appearance of men- 
struation. 

When the curetting has been done on an enlarged uterus acutely 
infected, as after abortion — say at the third month — the dressing 
should first be changed on the third day ; sooner if the temperature 
rises or other acute symptoms appear. Subsequent dressings are 
made whenever this one becomes saturated. After the uterus has be- 
come entirely clean, with non-purulent discharges, the use of ichthyol 
tampons is indicated, to overcome the existing subinvolution. This 
latter condition occasionally produces a simple hypertrophy of the 



208 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

mucosa, which will, at the subsequent one or two periods, give rise 
to menorrhagia, The larger the uterus the longer the treatment 
must be continued. After the first dressing the packing is loosely 
placed. The treatment is not painful. The uterus is always to be 
steadied by using the blunt bullet-forceps, hooked into the anterior 
lip. After abortion at the third month, irrigation with boiled 1 per 
cent, salt-solution or 4 per cent, boric-acid solution is also employed 
at the dressings. Strong antiseptics should never be used. The 
larger the cavity the more elaborate the treatment. Iii other words, 
these infected uteri are treated exactly as other discharging septic 
cavities, only here drainage is more difficult to obtain. 

Gonnorheal Endometritis. — Of all forms of virulent endometri- 
tis, this is one of the most common. 

Pathology. — Acute gonorrheal endometritis presents the same 
gross lesions as the septic form. Microscopically, we find that the 
gonococci penetrate but little below the surface, and are chiefly 
found in and under the epithelium. They follow the lymph- 
streams to a less extent than the staphylococci. Again, there is 
pus produced in true gonorrheal endometritis, but sloughing never 
follows this form of infection. No case has yet been reported of 
fatal primary gonorrheal endometritis. Systemic infection is not 
as severe as in the septic form. The great complication is salpin- 
gitis, by direct tissue extension from the uterus to the tubes. 
Chronic gonorrheal endometritis is very frequent, resulting from 
a subsidence of the acute form. Here the gonococci occupy the 
follicles and lie beneath the epithelium. They do not penetrate 
deeply into the mucosa, and do not extend along the lymph-spaces. 
Therefore they do not cause peritonitis and systemic infection except 
by extension through the tubes. Each menstrual period sees a 
greater or lesser increase in the invasion, and recurrent attacks of 
tubal disease are frequent. 

Symptoms. — Possibly some one or all the symptoms of gonor- 
rhoeal vaginitis or vulvitis are present, but they may all be absent, 
and the Hist and sole indication of infection may be the sudden onset 
of a virulent endometritis. There may be occasional rigors, fever, 
and great pain in the uterus. The temperature does not at first 
range high, and the initiative chill is not prominent. The pain 
in the uterus is of long continuance, with exacerbations. In 
a lew hours the discharge of muco-pus appears, often tinged with 
blood. If there be no extension of the infection, the symptoms 



INFLAMMATORY DISEASES OF THE UTERUS. 209 

of profuse discharge, slight fever, and pain gradually subside in 
ten days or less, leaving behind merely the symptoms of chronic 
purulent endometritis. 

The local symptoms are indentical with those of septic endome- 
tritis, but gonococci are found in the discharges. 

Fig. 87. 




Gonococci in cells and between cells (from specimen). 



Although these appear irregularly grouped in the pus- cells, 
yet on close inspection they may almost always be seen arranged 
in pairs (diplococci), the opposite surfaces of each pair being 
flattened like two Ds (OLD) back to back. They may be in groups 
only, and not show this diplococcus arrangement. Their manner 
of staining will then prove their character. 

Treatment. — If seen early and before the advent of any com- 
plication, local bloodletting should be obtained by puncturing the 
cervix in several places with a sharp bistoury, and then the uterus 
should be irrigated thoroughly with a saturated solution of boracic 
acid or a bichloride-of- mercury solution, 1:5000; after which a 
drain of iodoform gauze should be introduced ami the vagina- filled 
with the same material. In twelve hours both dressings may be 
removed, the uterus again irrigated, and more gauze inserted. This 
should be repeated several times daily. It is easier to subdue gon- 
orrheal than septic endometritis. If the first attempts to control 
the disease fail, we may be sure that the infection is a, mixed one, 

14 



210 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

and the treatment should be that for septic endometritis. If there 
be the complication ' of salpingitis or peritonitis, the operation of 
curettage is necessary. The body of the uterus is not the natural 
habitat of the gonococci, as the endometrium has a pronounced 
resistant power against them ; their home is in the cervix, the ure- 
thra, and vulvo- vaginal glands ; therefore they invade the corpus 
uteri in but a small number of cases, otherwise infected. 

Curettage. 
Curettage of the Uterus. — Admitting that in most cases patho- 
genic germs exist in the vagina and the cervical canal, the right 
does not lie with the surgeon to suppose the endometrium exempt 
in any given case of inflammation of the uterus. Therefore a meth- 
od must be adopted which presumes they are present in all cases. 
The instruments necessary for performing a curettage are — a specu- 
lum, double tenaculum, heavy applicator, curettes, uterine dilator, 
fountain or bulb syringe, and an intra-uterine packer. The opera- 
tion is best clone with the patient in the lithotomy position and with 
Kelly's pad placed under the hips. The lithotomy position is pref- 
erable to Sims', as irrigation is easier, and at any stage of the opera- 
tion a bimanual examination may be made. The solution for irri- 
gation is preferably a saturated solution of boracic acid, but bichlor- 
ide of mercury 1 : 4000, or even boiled salt-solution (7 : 1000), will 
answer. The vaginal canal and instruments should be sterilized 
(see Technique). Instead of sponges, swabs of cotton wet in bi- 
chloride-of-mercury solution are used. Any stiff dilator will 
answer the purpose, but those with screws should be employed care- 
fully, for the blades are apt to tear the tissues, as the screw renders 
it impossible to relieve the pressure until too late. Goodell's instru- 
ment is a proper one. The vulva having been shaved, the patient 
cleansed and in position, the speculum is introduced and held by 
the assistant on the patient's right. The anterior lip of the cervix 
is seized with the double tenaculum, pulled down as far as desired, 
and given in charge of the same assistant, whose left hand rests on 
the pubic bones. In this way the uterus is held immovable. By 
bimanual palpation the size and position of the uterus are deter- 
mined. The cervix should cautiously be dilated bilaterally, the grip 
relaxed, the dilator turned a little, and dilatation made in the new 
position of the instrument ; in this way by alternately dilating 
around the entire circumference of the cervix the canal will readily 



INFLAMMATORY DISEASES OF THE UTERUS. 



211 



and safely be dilated to an inch or more. It must not be forgotten 
that we are working in undeveloped unstriped muscular fibre, to 
overcome the force of which too sudden pressure must not be used. 
Dilatation by graduated sounds is not advisable, inasmuch as the 
pressure is made against the hold of the tenaculum, and either 
insufficient dilatation is made or the tenaculum tears the tissues. 
Under any circumstances the traumatism induced is much greater 





Fig. 88. 


S; M 


■ : '' -, ' .'-"/ ' .- < 




PPPF 


'Hi 


I!) 




.Ml 




'IMfl:!^ 




- -^^m 




^^y 



Instruments in Position for Dilatation of the Cervix Uteri. 

than when the steel instrument is used as described. Besides, 
the dilatation obtained is not sufficient to destroy the action of 
the local sympathetics, upon which depends the uterine colic 
and the expulsion of the dressing, as observed and complained of 
by those who use the graduated sounds. After dilatation the uterus 
should be washed out by means of the small nozzle of the syringe, fol- 
lowed by the use of the curette. As large an instrument as can be 



212 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

introduced should be used. Gently introducing the curette, it is with- 
drawn, its cutting face downward, and by reintroductions and with- 
drawals the whole organ is systematically scraped. The small size is 
then used if the uterus be firm, and the openings of the tubes and 
lateral angles scraped. The instrument is then turned so as to curette 
the fundus by a sweep from side to side. The danger from curettage 
lies not in the proper use of the instrument, but in introducing it' 
roughly and with force. The instrument should be held as is a pen- 
cil, and used with a delicate touch. Blunt curettes are useless for 
this work. If a surgeon must use such because of the supposed 

Fig. 89. 



0- 

Sharp Curette. 

danger attaching to the sharper instrument,' it is questionable 
whether he should do the operation at all. Again — and this is 
important — the dull curette at best scrapes off only the epithelial 
and softer external portions of the mucosa and opens up the lymph- 
channels. Thus its use may be harmful ; for if a septic infection 
be local,' and the epithelium of the rest of the organ has sufficient 
resistant power against the cocci, the procedure but removes this 
sole protection against a general infection without going sufficiently 
deep to remove the cocci, and thus creates for the germs a new field 
for extension. So it is manifest that in septic cases, at least, the 

Fig. 90. 



■m=* 



/T^-- 






Bulb Syringe. 

fancied safety of the dull curette, apart from its inefficiency, is a 
delusion. The object of the operation is to remove the entire 
endometrium, so that the cytogenic embryonic uterus may produce 
a new one under propitious circumstances. Following the curet- 



INFLAMMATORY DISEASES OF THE UTERUS. 



213 



tage, the uterus is to be irrigated again thoroughly. If the organ 
is much hypertrophied, the entire cavity should be swabbed out 
with tincture of iodine on an applicator, or the application made by 
means of the iutra-uterine syringe. 

Fig. 91. 



Braun's Intra-uterine Syringe. 

Uterine Tamponade. — The gauze is introduced in one long 
strip. If the cervix be thoroughly well open, the gauze may be 

Fig. 92. 




Instruments for Applying the Intra-uterine Tampon. 



gotten in with the packing forceps. It is usually, however, difficult 

on account of friction to tampon the uterine cavity except through 

Fig. 




Tamponing the Uterus with Iodoform Gauze by means of the Intra-uterine Packer. 



an intra-uterine speculum, in which case it is first necessary to dilate 
the cervix. The uterus should be packed as tightly as possible, and 



214 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

the end of the gauze left projecting from the cervical canal. The 
canal itself should be only loosely packed, else the gauze will not 
drain the cavity. A light dressing of gauze is then applied to the 
vagina. The patient should not be allowed to soil the dressings 
with urine if it can be avoided. After each urination or movement 
of the bowels the vulva and perineum must be cleansed by a free 
use of a saturated solution of boric acid or other cleansing solution. 
When repair begins, the uterus being relieved of the septic 
process, the new leucocytes and plasma-cells are not forced to exer- 
cise their phagocytic property by battling with pathogenic germs, 
but the plasma-cells have a healthy pabulum, and devote their entire 
energy to the work of regeneration. It is not merely non-sup- 
purating repair ; it is histological growth. 

Curettage in Acute Pelvic Inflammations. 

The question of the propriety of curetting the uterus in the 
presence of acute tubal and peritoneal manifestations may be dealt 
with here. If the article on the anatomy of the endometrium be 
consulted, and one reflects that pelvic peritonitis is very rare in 
men, he will be forced to believe that the pyogenic germs reach 
the woman's pelvis through the uterus. That granted, it will 
become apparent at once that the sequence of pathological changes 
must either be endometritis, salpingitis, and peritonitis ; or endo- 
metritis, metritis, pelvic lymphangitis, and peritonitis. The ques- 
tion then is proper : Does this causative endometritis cease the 
moment the pelvic complication arises ? Surely it does not. The 
peritonitis is not a disease per se, but merely an effort on the part 
of nature to check a disease. One of its first acts is to shut off the 
tubal inflammation from the peritoneum, by closing with adhesions 
the fimbriated opening of the Fallopian tube, thus cutting off further 
extension through that channel or, in case the sepsis travels through 
the lymphatics between the folds of the broad ligaments, by effusion 
of lymph to isolate the infected area, So rapid is absorption in this 
direction, in some few cases, that the general peritoneum may appear 
normal, and yet evidences of the infection present themselves on the 
diaphragmatic peritoneum as the first point above the pelvic lesion. 
It is irrational, then, to consider these septic conditions in the light 
of their results only, ignoring the original source of the trouble, 
which still remains septic and continues to feed the fire. So long as 
the infectious focus remains, just so lomr will the peritoneum throw 



INFLAMMATORY DISEASES OF THE UTERUS. 215 

out lymph. When once the septic focus is removed, the lymph- 
effusion will cease, and the possibility of further extension from 
the original source is out of the question. The patient, relieved 
from the ptomaine-poisoning, ceases to vomit, the emunctories work 
properly, and the digestive functions are well performed. From 
a state of acute poisoning, the case has, by this removal of the 
causative disease, been converted into one having only the results 
of the infection, though these are grave. It is eminently proper, 
therefore, in theory, to curette the uterus before dealing with the 
sequela?, in all cases of acute septic endometritis with salpingitis or 
peritonitis. In practice this theory has been proven correct and the 
results positive. Too many successful operations in cases of both 
septic and gonorrheal origin have been reported to admit of ques- 
tion as to the propriety of the method. Since attention was first 
drawn to the subject it has been adopted by many surgeons as 
the first, operation indicated in these cases of acute septic endo- 
metritis with tubal and peritonitic inflammations before the com- 
plications are dealt with. If, as is at times the case, it be deemed 
necessary to deal first with the complications, the diseased endo- 
metrium should subsequently be treated if the uterine symptoms 
persist. 

The other methods of treating these cases are by the "expectant" 
plan of opiates and poultices, or immediate celiotomy — a procedure 
extremely irrational in view of what we now know of the pathog- 
eny of pelvic inflammations. In no other part of the body is the 
unsurgical rule applied of removing the result of acute septic infec- 
tion and ignoring the cause. Still more is the abdominal section 
contraindicated, as under these conditions it is made at the worst 
possible instant. Tubal abscess must ultimately be removed and 
adhesions severed. But if the primary celiotomy be made, it is in 
a mass of effused lymph and distended and adherent guts, and often- 
times in the presence of acute infectious pus — pus which in several 
weeks or months will be comparatively innocuous. 

When the curettage is properly performed the improvement in 
the local condition is at times marvellous. Irrespective of its effect 
upon the result and technique of a future celiotomy, curettage is 
positively indicated in every case of acute tubal and peritoneal dis- 
ease, when there is even a suspicion that the infection originated in 
the endometrium; that is, in the majority of cases. Some of the 
acute symptoms, as fever, arise not from the pus-focus in the tube 



216 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

or ovary, for such is more or less isolated from the general absorp- 
tive system, but from the septic endometrium pouring into the 
lymph-streams an endless supply of septic material. If there is 
a distinct pus-accumulation in the pelvis, this will have to be sepa- 
rately treated, for curettage has no influence upon such conditions. 
It is in cases of acute purulent salpingitis — cases presenting tubes 
deeply injected, swollen, friable, and occluded, but which upon sec- 
tion reveal little or no dilatation of their lumen — that curettage secures 
its greatest results. Furthermore, if by any possibility there is no 
tubal disease, the curettage will remove every trace of the infection. 
In these tender women positive and precise statements of the pelvic 
changes are often difficult, and masses of lymph-effusion are fre- 
quently interpreted as tubal abscess. The method is no longer new 
and experimental, but is the one accepted by many American 
gynecologists. Brought to a case of acute salpingitis and perito- 
nitis, the indications are, not for a brilliant removal of the adnexa, 
but rather to adopt that method which will preserve the woman 
from those gross changes in the peritoneum or adnexa, for which 
so many cceliotomies are done, and to save her, if possible from 
an abdominal section. So wonderful is the ability of the per- 
itoneum to absorb and repair, that it should in all acute cases 
be given an opportunity. In the light of its causation, of its 
pathology, even of its results, acute tubal and peritoneal inflam- 
mations of uterine origin, are to be treated by curettage and gauze 
packing as the primary operative procedure. One of three meth- 
ods must be adopted with these cases: either poultices and hot 
douches, curettage, and treatment of the uterus as any septic 
cavity, or a primary celiotomy. The first is the method of the 
midwife, and merely allows the infection to work its will in the 
pelvis. The second is surgical in every sense of the word ; while 
to adopt the third in every case, stamps a man as blind to reason 
and to the work of other men, and as willing to open a fellow- 
being's abdomen rashly and unnecessarily. 

We know that septic endometritis has but a small percentage of 
mortality, but what frightful ravages it makes in the peritoneum 
and adnexa! We know that many men apply the curette improp- 
erly, and that possibly women are oftentimes worse after it than 
they would be were they let alone. But should faulty technique 
and ignorance deter us from laying down the proper treatment? 
Therefore the rules — and golden ones they are too — may be enun- 



INFLAMMATORY DISEASES OF THE UTERUS. 217 

ciated : 1, treat all cases of endometritis in the light of its possible 
results ; 2, treat all cases of septic and specific endometritis, with 
complications, in the light of their causes. If a sloughing polypus 
causes acute peritonitis, shall it not be first removed ? If a slough- 
ing endometrium causes the same complication, shall not the uterus 
be cleansed ? 

Method of Reproduction of the Endometrium. 

Repair and reproduction, after removal of the endometrium, is ac- 
complished by means of the lymphoid cells and multiplication of the 
epithelium and plasma cells. If these are met by pathogenic germs 

Fig. 94. 




in numbers, their whole effort is concentrated upon the conquest 
of the germs. Consequently the leucocytes die in large numbers 
and form pus, while the plasma-cells, deprived of their normal 
pabulum (leucocytes), are limited in the function of tissue-formation, 
and result largely in the production of connective tissue. 

Hence it is that after an aseptic curettage the endometrium is 
reproduced in a normal condition in about two months. Con- 
versely, after the membrane has been removed by means which 
result in suppuration, the endometrium is reproduced but imper- 
fectly. 

Fig. 94 is taken from a uterus three months after curettage, 
and it will be noticed that in almost every particular it is a normal 
structure. It resembles the endometrium of a young girl soon 
after the menstrual function has become established. 



218 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



This specimen (Fig. 95) was removed from a woman to whose 
uterus chloride of zinc had been applied fifty-three days previously. 




Vertical Section of the Uterine Mucous Membrane Fifty-three Kays after the Application of a Causticr 
a, a, epithelium; b, connective tissue; c, c, c,c, section of the glands which have undergone cystic- 
degeneration ; d, d, tubular glands enormously dilated ; m, muscular tissue of the uterine wall. 



It will be noticed that the condition here is one of atrophic endo- 
metritis of a pronounced degree, with marked interstitial hyper- 
trophy — exactly similar to chronic interstitial endometritis. The 
gland-follicles are caught in the new connective tissue and form 
cysts, while the surface of the membrane is covered by epithelium ; 
the glands are scarcely to be found. 

These plates prove very conclusively, the facts which have been 
amply substantiated by clinical experience. It is fair to assume 
that any caustic agent, which can penetrate as deeply as chloride 
of zinc, will have the same effects. Such agents are nitric acid, 
caustic soda, and very strong electrical currents. Similar but less 
marked changes are induced by the use of strong antiseptics, such 



INFLAMMATORY DISEASES OF THE UTERUS. 



219 



as carbolic acid and bichloride-of-mercury solution, and too free ap- 
plications of tincture of iodine when these are used after curettage. 
The manner in which reproduction of the mucosa ensues is well 
shown in the accompanying illustrations. 




<?___^3> 



m&^s~z&y&=$^Z 



Perpendicular Section of the Uterine Mucous Membrane Thirteen Days after Curettement : a, ft, 
epithelium, newly-formed ; e, newly-formed connective tissue. 

The exact method of reproduction of the endometrium is not 
definitely known. The first step is the extrusion of lymphoid and 
plasma cells upon the raw surface produced by the curettage. These 
rapidly form a layer covering the entire inside of the uterus with 
flat cells which ultimately become ciliated cylindrical epithelium. 
The subjacent tissue grows so rapidly and the epithelial cells mul- 




Perpendicular Section of the Uterine Mucous Membrane Thirty-one Davs after Curettement: a, a, a, 
cylindrical epithelium ; b, d, proliferating cells in the deeper part of the epithelium; c, new-formed 
connective tissue. 

tiply so fast that the surface of the membrane is thrown into a 
wavy line, which, as the process continues, takes on the charac- 
teristics of a plane surface studded with innumerable crypts. Thus 
is the new, perfect endometrium evolved from the basement mem- 
brane, after curettage. 

The after-tkeatment of cases of curettage for acute tubal or 
peritoneal disease is as important as the operation. In all eases of 
curetting after conception, irrigation should be practised on chang- 



220 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

ing the dressing. The details of the treatment are governed entirely 
by the two great principles : cleanliness and drainage. It would be 
folly to remove the primary packing from a large uterine cavity and 
not keep the cervix open ; this would merely result in a reinfec- 
tion, as curettage and irrigation do not remove every particle of 
sepsis : the cocci are in the lymphatics and often in the venous sin- 
uses. After curettage, the septic uterus must be treated as any other 
septic granulating cavity, with this distinction : packing should cease 
when the uterus is reduced in size and its secretions become free 
from pus-cells. Further treatment may be necessary if the organ 
remains enlarged. Curettage does not absolutely prevent those symp- 
toms which follow subinvolution, as hemorrhages. Therefore, a curet- 
tage done for infection in a puerperal uterus may, later on, have to 
be repeated for the hypertrophic membrane which gives rise to the 
bleeding, and which forms upon the enlarged uterus. Hence the 
use of tampons wet in ichthyol (10 per cent.) and boroglyceride 
(90 per cent.), applied twice a week to the cul-de-sac, is to be recom- 
mended in all cases of enlargement of the uterus. It will be found 
that the ichthyol tampons will very much lessen the pain which 
accompanies salpingitic and peritonitic effusions. It is wise in cases 
of retroposition to tampon the vagina with gauze, so applying it that 
it will act somewhat as a pessary in supporting the fundus. As a final 
caution the most scrupulous attention to every detail of aseptic work 
must be employed at each dressing, lest the case be reinfected. This 
point cannot be too strongly insisted upon. Opium should not be 
used. The bowels should be kept open. After curettage the menses 
are apt to occur a few days earlier than the usual date. All treat- 
ment should be suspended during this period, except where the 
uterus is septic. Menstruation has no effect upon the routine 
methods other than to require more frequent changing of the 
dressings. 

Electrical Treatment of Endometritis. 

The advocates of electricity in the treatment of endometritis 
have not, as yet, established any substantial principles, applicable 
equally well to all parts of the body. They do not tell us the 
effect of electricity upon the various cocci, or its influence upon 
the living cell. Does it cause unstriped muscular fibre to con- 
tract or to become flaccid? What is its influence upon the 
white blood-corpuscles and plasma-cells? Take its application in 



INFLAMMATORY DISEASES OF THE UTERUS. 221 

cases of simple endometritis. The application of even slight 
currents causes the epithelium to exfoliate. The negative pole 
with from 50 to 70 milliamperes for ten minutes, the strength some 
authorities advise, does more than cause exfoliation of the epithelium 
— it destroys tissue for a slight distance. In septic endometritis it 
is said that the current destroys the cocci. Staphylococci will sur- 
vive being dried upon a cover-glass for ten days, and are then 
destroyed by exposure of not less than ten minutes to boiling 
water. Will even 100 milliamperes do that? But granted that 
the currents used will destroy cocci, what effects have they other 
than this? A very mild electrical current stops the ameboid move- 
ments and checks the processes of cell activity, while it lasts. Cur- 
rents of moderate intensity destroy the vitality of all protoplasm 
within reach of the currents. The interpretation of this is very 
simple. It means that currents much too light to prove germicidal, 
cause exfoliation of the protecting epithelium, destroy the property 
of diapedesis of the white blood-corpuscles, and destroy the karyo- 
kinetic property of the cells or their ability to multiply. These 
currents rob the locality to which they are applied of nature's sole 
defenses against pathogenic germs — epithelium, white blood-corpus- 
cles, multiplication of cells. 

By curettage, dead tissue and useless cells are removed. Useful 
living tissue is not destroyed, but the plasma-cells of the various 
tissues are given an environment propitious to their development 
and growth. Can electricity remove the entire septic endometrium 
in a few minutes, and iu a month produce a new healthy one 
capable of forming a placenta and nourishing a fetus? The 
surgical methods here laid down can. Conception has taken place 
five weeks after a curettage for purulent endometritis. 

The great scientific truths upon which, deductively, the method 
by curettage with its positive results, has been produced, cannot 
be ignored for another, based upon empiricism, and unsuccessful 
empiricism at that. The established surgical rules which, the world 
over, are accepted for inflammations in other parts of the body, are 
applied to the treatment of endometritis ; and until gynecologists 
who practise the electrical treatment, can lay down for our guidance 
the positive indications to be filled, and reasons for their proposi- 
tions, indications which are scientific and facts which are not mere 
personal statements, the use of this measure cannot be recommended. 
Glittering generalizations will not suffice. What they propose to 



222 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

accomplish within the hidden organs must have been successfully 
tried on those within view. If fibrous tissue may be removed within, 
so may it without. If suppuration may be checked within, ample 
opportunity presents for testing it without. If glandular hypertro- 
phy is corrected in the uterus, so may it be elsewhere. A few years 
back, when gynecology consisted merely of the dictum of one or 
two world-famed men, the electrical treatment might have become 
established. To-day, in the critical light of modern research and 
the generous distribution of knowledge, it exists, not because of true 
merit, but through the timidity of suffering womankind, who grasp 
at the hand offering relief " without an operation." 

Inflammation of the Cervix. 

The cervical mucous membrane, because of its anatomical cha- 
racteristics, is less often the seat of destructive inflammatory changes 
than the endometrium. Classification of changes in the cervix is 
usually made according to the clinical appearances. This is too 
confusing and elaborate. Every case of cervical disease which is 
neither malignant nor tubercular may be placed in one of the 
following classes : 

Septic and Gonorrheal Endocervicitis. 
Glandular Endocervicitis. 
Cervical Hypertrophy. 
Cicatricial Stenosis. 

Septic and Gonorrheal Endocervicitis. — Acute gonorrheal and 
septic processes here are not important, except in view of the 
possibility of extension to the endometrium. The cervical mucous 
membrane is dense, with few lymphatics, and drainage is so readily 
obtained, that pelvic lesions from cervicitis are rare if they ever 
occur. Acute specific infection of the cervix seldom remains local, 
but soon becomes general in the uterus. It is as a chronic inflam- 
mation that we most often see cervical lesions existing alone. Its 
compound racemose glands do not readily shed their epithelium, 
and cocci rest for great lengths of time', attenuated and quiet, in their 
secretion, even without producing purulent discharges. This fact 
being known, we are able to explain the development of latent gon- 
orrheal endometritis and accept the possibility of auto-infection. 
We can also account for those apparently inexplicable cases of 
uterine and pelvic inflammation which sometimes follow the pas- 



INFLAMMATORY DISEASES OF THE UTERUS. 



223 



sage of an instrument through a cervical canal not previously 
cleansed. 

Glandular Endocervicitis. — This takes the form of enlargement 
of certain portions of the normal folds. There is a projection or 
budding of the membrane, and as this increases the mouths of the 
glands become obliterated. The imprisoned glands continue to 
secrete, and the enlargement thus becomes pedunculated, forming 




Mucous Polypi from the Interior of the Cervix and upon the Surface. 

a true polypus. Again, the epithelium of the cervix may be 
exfoliated as the result of a vicious discharge from above; or 
injuries from below, such as lacerations, may cause the production 
of granulations and erosions. But, contrary to the general opinion, 
instead of there being a loss of tissue with this condition, the eroded 
surface projects beyond the line of healthy membrane. As a result 
of long-continued irritation to its glands the connective tissue of 
the cervix may become moderately increased, thereby occluding the 
glandular canals, and in this way the entire cervix may become 
riddled with cysts, constituting cystic degeneration. Some of these 
cysts contain clear fluid and some pus. 

Symptoms. — As all forms of cervicitis entail an enlargement of 
the cervix, there is the constant symptom of weight and heaviness in 
the pelvis. Acute septic and gonorrheal cervicitis is usually asso- 



224 



AN AMERICAN TEXT-BOOK OE GYNECOLOGY 



ciated with some other symptoms of these infections, but, if occur- 
ring alone, the special symptoms are, that the cervix is engorged, 



Fig. 99. 




a, b, Simple Papillary Erosion 



lar, slightly enlarged. 



often eroded, and secreting its peculiar mucus, tinged with blood 
perhaps, but always very purulent. The cervical canal is often 




Simple Follicular Cysts of the Cervix. 



gaping. Removal of this mucus is not followed by pus from above, 
showing the endometrium to be uninvaded. The several cocci are 
found by the microscope. The symptoms of chill and fever are 



INFLAMMATORY DISEASES OF THE UTERUS. 225 

wanting. Upon the subsidence of the more acute phenomena there 
will remain but the purulent discharge and some erosion. As has 
been said, acute septic and gonorrheal cervicitis tend to travel 
upward, and rarely will a case be seen before it has done so, owing 
to the absence of general symptoms due to the cervicitis alone. 
Glandular cervicitis, especially when it has gone on to the forma- 
tion of polypi, produces a purulent (often profuse) discharge, in 
addition to the subjective symptoms of bearing-down and weight. 
The most prominent reflex phenomena accompany cystic degener- 
ation and interstitial cervicitis. Headache is constant and the 
patient is very nervous. She is very emotional and prone to 
hysteria, the nervous symptoms being fairly well proportionate to 
the amount of interstitial change and follicular degeneration. The 
cysts project from the vaginal aspect of the cervix as rounded 
nodules, like blisters. If one be pricked, nothing escapes, but gen- 
tle pressure forces out a pearl of tenacious mucus. They occur not 
only on the surface, but in the deeper parts of the cervix also. In 
glandular cervicitis the canal is usually open, and by separating 
the lips the enlarged glands may be seen. 

Treatment. — Acute gonorrheal and septic endocervicitis are to 
be most vigorously treated. The plug of mucus must be removed, 
and the application of powerful antiseptics made, as pure carbolic 
acid, care being taken not to invade the inside of the uterus. The 
condition is very hard to check, and is extremely liable to become 
chronic ; but even then there is no better application than carbolic 
acid. Erosions due to purely local causes, as pessaries, can readily 
be cured by removing the cause and keeping the parts clean. 
Erosions are almost always dependent upon some form of glandular 
inflammation, either in the cervix or above, and are to be relieved 
by curing that cause. The association between cystic degeneration 
and beginning epithelioma is very close, while polypoid cervicitis 
is simple adenoma. Therefore the operative procedures directed 
to the cure of the latter need not be so radical as for the former. 
Inasmuch as polypoid cervicitis is seldom general, excision of the 
polypi is all that is necessary for isolated growths. t This can be 
done under cocaine appplication. Should, however, it be associated 
with much interstitial hypertrophy, or the polypoid growths be 
general over the cervix, the excision of a portion from each lip 
will be of benefit in producing contraction. 

A general cystic degeneration is amenable to the wedge-shaped 

15 



226 AN A ME RICA N TEXT-B O OK OF G YNECOL OGY. 

amputation of the cervix, an illustration and description of which 
will be found in the chapter on Malignancy. It is a good opera- 
tion, giving most excellent results, and many cases now subjected to 
Emmet's operation of trachelorrhaphy would be better operated 
upon by this method. 

Cervical Hypertrophy. — Cervical hypertrophy may be so great 
as to simulate prolapsus, and, indeed, it may produce a certain 
amount of descent, but the fundus is always found higher than in 
prolapsus. The total length of the uterine canal is greater, the 
increase being chiefly in the cervix ; there is no rectocele, but a 
spurious cystocele accompanies the condition, as the urethra and 
base of the bladder follow the increased growth of the cervix. 
Still, the caution is necessary, that in amputating these hyper- 
trophied cervices great care be exercised lest the bladder be opened, 
as the hypertrophy may spring from near the os internum, in which 
case the vesical organ will be dragged down with it. The sound in 
the bladder, however, will show the relations of that organ to the 
hypertrophy. The cervix may be so generally inflamed and, at the 
same time dilated, that the membrane will be'rolled out, forming a 
true ectropion, and presenting the evidences of glandular hyper- 
trophy, even amounting to glandular polypi. Excision is here 
necessary by the method already indicated. 

Cicatricial Stenosis. — As a result of operations, inflammations, 
and application of caustics — rarely as a congenital lesion — we may 
have a cervical canal so contracted as to form a true stenosis or an 
atresia; the condition may even give rise to hematometra, and 
require treatment as for congenital atresia. It is amenable to the 
operation of bilateral incision (splitting the cervix bilaterally by 
means of knife or scissors to the internal os), followed by forcible 
dilatation. The after-treatment is long and tedious, and the patients 
are forced to remain under observation for a great length of time. 
This is necessary because the operation is usually done in a field of 
cicatricial 'tissue, which tissue possesses an inherent tendeney to con- 
tract, repeated or continuous dilatation being necessary for its pre- 
vention. Stem pessaries are here worn with advantage for a space 
of some months. 

In the milder cases the bilateral incision is to be followed by 
gauze packing for three weeks, the packing being limited to the 
cervix alone. 

These incisions, followed by dilatation, arc covered over by a 



INFLAMMATORY DISEASES OF THE UTERUS. 227 

modified form of mucous membrane in a remarkably short time. 
Stem pessaries are not necessary, unless the tissue be newly-formed 
cicatricial tissue ; in other cases the cervix will remain dilated 
around even a very fine filament of gauze, and while the lat- 
ter is in place the formation of the new membrane goes on 
speedily. 

In considering all these questions involved in the treatment of 
diseases of the uterus it must not be forgotten that the organ is em- 
bryonic and capable of reproducing its tissues to a certain extent, 
but reproduction does not take place from scar-tissue or in the pres- 
ence of suppuration. The faculty of reproduction from the basement 
membrane, when once the mucosa is entirely removed, is not inher- 
ent in the cervical mucous membrane. This, once removed, is never 
re-formed. 

Metritis. 

This condition is of very minor importance, because it is merely a 
name for certain changes in the muscular walls, secondary to more 
important conditions. An idiopathic metritis does not exist : it is 
always secondary to, and an extension of the inflammation of the 
endometrium. Inflammation of the muscularis uteri follows all 
acute and many chronic infections of the mucosa. The treatment 
of the two conditions is identical, and has already been fully con- 
sidered under Endometritis. A low form of tissue change also 
accompanies the various neoplasms, flexions, and versions. These 
will be described in the proper places. 

Subinvolution. 

The condition known as subinvolution which follows labor is 
not, per se, a disease, but merely an association of conditions result- 
ing from a common cause. The uterus has not yet fully undergone 
those retrograde changes which normally follow labor. It is en- 
larged in all its diameters and the mucosa is thickened. The organ 
being heavy and its walls softened, it shows a tendency to sink low 
in the pelvis or take a retroposition. 

The intimate histological condition is one merely of fatty, en- 
larged, unstriped muscular fibres, enlarged vessels and lymph- 
spaces, and glandular hypertrophy of the mucosa. It can scarcely 
be termed strictly a pathological condition, rather is it an incomplete 
physiological one. When it has persisted for some time, fibrous 



22S 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



tissue hyperplasia does take place in the muscular walls, and the 
change in the mucosa becomes a permanent hypertrophy. 

Symptoms. — If the menses have returned, they are increased in 
amount, but are not painful. If the engorged organ is low down, 
retro verted or retroflexed, the symptoms present are of constant 
and severe backache, together with bearing- down pains. 

Usually all patients complain of a sense of weight and heaviness 
in the pelvis. There are present the general symptoms of anorexia, 
costiveness, anemia, and general malaise. Women with subinvolu- 
tion are at times subject to melancholia, which may even amount 
to a temporary insanity, not acute. Mania following labor and due 
to infection by streptococci is not to be confounded with this mild 
aberration of intellect. This condition is not a frequent one, and, 
when found, is generally in stout, plethoric women. 




Subinvolution. 



Examination shows the enlarged, soft uterus, possibly low down 
or retroposed. It is not tender in uncomplicated cases, but is 
extremely so in the presence of an accompanying endometritis. 

Treatment. — The general conditions predisposing to this mal- 
ady must be met ; therefore strychnia and cinchona before meals, 
and wine and iron, are indicated. The combination of ergotin and 
quinia is exceedingly efficacious. 



INFLAMMATORY DISEASES OF THE UTERUS. 229 

Locally, iutra-uterine applications of tincture of iodine, with the 
supporting and depleting tampon of ichthyol 5 or 10 per cent, in 
50 per cent, boroglyceride, twice a week, are all the requisites for 
effecting a cure, in the absence of any acute symptoms. Hot 
vaginal douching should be employed twice each day between treat- 
ments. If the hemorrhages are of serious moment, curettage not 
only removes that factor, but materially hastens the involution. 
General treatment is of great importance. 

If subinvolution be neglected, the organ is prone to take on 
almost any form of inflammatory change, and is especially liable to 
septic infection. The condition materially reduces the organ's 
resistant power against pathogenic germs. Many cases of grave 
pelvic lesions and uterine displacements may be traced to neglect 
in guarding against this condition after confinement or abortion. 
Subinvolution is very frequently caused by a septic or specific infec- 
tion of the uterine cavity in the puerperal woman, resulting in an 
endometritis. Such cases resolve themselves eventually into a true 
condition of metritis and endometritis, and are to be dealt with as 
such. 

Hyperinvolution. 

The condition known as hyper- or super-involution follows labor, 
and is due to causes unknown. The natural involution of the 
uterus following labor reduces the size of the organ slightly below 
its normal condition, but subsequently, within the course of a few 
weeks, this loss is regained. Occasionally involution does not cease 
at this point, but continues beyond the physiological condition, until 
the womb becomes, at times, even as small as an inch or an inch and 
a half in depth. The causes which change the physiological process 
into a pathological one are obscure, and can rarely be detected. 
Fortunately, the occurrence is rare, as the condition is extremely 
difficult to treat successfully, most commonly baffling all the efforts 
of the physician. 

Painful and scanty menstruation are common attendants, and are, 
in fact, the principal symptoms. The dysmenorrhea is of a severe 
and persistent type, usually appearing prior to the flow and lasting 
throughout its whole course, and is undoubtedly due to the atrophic 
condition of the endometrium. The ovaries may or may not be 
involved in the process : should they become involved, it would be 



230 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

one more causative factor added to the dysmenorrhea, and would 
exaggerate that condition. 

The physical examination, together with the history, renders the 
diagnosis clear. The uterus is found small and its walls of firm 
consistency, at times almost fibroid in character. The depth of 
the uterine cavity is reduced from two and a half inches, the normal, 
to one or one and a half inches. 

The medical treatment of the disease is not productive of any 
assured success. It consists in rendering the patient's general health 
as nearly normal as possible, at the same time stimulating the uterine 
muscle. Probably electricity, both general and intra-uterine, gives 
as much promise of success as anything. Should the physician's 
efforts be attended with good results in accomplishing a return of 
the uterus to its normal size, the menstrual flow will become more 
natural in quantity and the dysmenorrhea will gradually disappear. 
Most often the treatment consists in simply controlling the pain. 
Efforts in this direction will be accomplished by much the same 
means as given in the chapter on Dysmenorrhea. As a rule, the 
patients will have to be content to bear their sufferings as best 
they may, with what amelioration drugs will give, until the change 
of life ends their period of probation. Should the pain become so 
great as to render life miserable, a resort may be had to ovariotomy 
with the view of bringing on an immediate menopause. The 
justification of this procedure must rest entirely with the individual 
case, the event being determined by the amount of suffering and 
the failure either to cure the condition or to relieve the symptoms. It 
is far better to perform the operation of removal of the ovaries 
than to have continuous resort to opium, with all its attending 
dangers. The question of childbearing need hardly be considered, 
if for no other reason than that these women are rendered sterile by 
their condition. Pregnancy, if it- could be brought about, would 
probably produce a cure, or rather it might be nearer the truth 
to say that this condition would be proof that a cure had been 
accomplished, as pregnancy is most improbable until there is a 
return to the normal condition of the endometrium. 



LACERATIONS OF THE SOFT PARTS. 



Laceration of the Ceevix Uteet. 

Laceration of the cervix is one of the commonest of all gyne- 
cological affections, and is the consequence of dilatation of the cer- 
vix, whether by the head of the child in labor or by the uterine 
dilator in the hands of the gynecologist. 

The tear occurs in consequence of the refusal of the external 
os uteri to dilate sufficiently to allow the head of the child to pass, 
and the result is a rupture which extends a variable distance up into 
the uterus and into the vault of the vagina along the base of the 
broad ligaments. 

These ruptures are with remarkable uniformity bilateral ; occa- 
sionally unilateral or stellate. 

Deep fissures, unaccompanied by lateral tears, occupying the 
median line in front or behind, are almost without exception sus- 
ceptible of -some other explanation. Posteriorly, for example, 
many cases are observed in which the operation of discision, or split- 
ting of the cervix for the relief of dysmenorrhea, had been prac- 
tised. Anteriorly, a median split is often significant of the surgeon's 
knife or scissors, used to incise the rigid os, or more often it arises 
from the use of the obstetric forceps. 

The immediate danger arising from these tears is the ready access 
afforded for the invasion by septic germs of the pelvic connective 
tissue. This is to be prevented by unusual care during the confine- 
ment and puerperium, in avoiding sepsis by cleansing the vagina 
before labor where there is any purulent discharge, and by main- 
taining an aseptic condition during the confinement. 

If it is necessary to handle the cervix, this should be done 
with a sterilized rubber stall drawn over the finger. After the 

231 



232 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

confinement, douches should not be given as a prophylactic, 
but become necessary when the existence of an infection has de- 
clared itself. 

It is not proper, in view of our methods of to-day, to attempt the 
immediate repair of cervical tears. When, however, there is a con- 
stant flow of arterial blood, trickling in a small stream from between 
the labia, and digital examination reveals the presence of cervical 
laceration, it will be found at times that the hemorrhage proceeds 
from the rupture of a cervical artery. In such a case an immediate 
operation must be undertaken. The patient should be brought to 
the edge of the bed in the dorsal position with the thighs flexed 
upon the abdomen and the posterior vaginal wall retracted with a 
Sims speculum. The blue, soft lips of the cervix appear low down 
in the vagina ; they should be grasj^ed by a pair of bullet-forceps, 
drawn down to one side, and the tear from which the bleeding comes 
exposed. The operator then passes a suture deeply through the 
tissue, in such a way as to include the vessel and serve at the same 
time to approximate the torn lips. Two or three similar sutures 
below this uppermost one will serve to secure an accurate approxi- 
mation of the lips throughout. The sutures must not be tied tightly, 
and no dressing should be applied in the vagina. Such an operation 
will be almost invariably successful. The sutures may be left in 
place for six or eight weeks if necessary. 

Where an operation is unnecessary for the purpose of control- 
ling hemorrhage, the patient is to be treated on the expectant plan 
and if no sepsis occur, a spontaneous closure of the laceration will 
take place. 

Some months or some years after a confinement one of three 
appearances will be observed in cases of laceration of the cervix: 
First, the cervix presents a normal appearance with a slight or 

Fl«. 102. Fra. 102 





and Front Views of a Simple Bilateral Laceration, requiring no treatment. 



a marked notch on either side ; secondly, the cervix presents two 
well-defined lips, and is even torn down to the vaginal vault : the 
lips are soft, flaccid, and not thickened ; thirdly, the tear is not so 



LACERATIONS OF THE SOFT PARTS. 233 

evident on inspection as in the last variety, but the cervix appears 
thickened, and hardened, its angry red centre presents the appear- 





Front View of a Unilateral Laceration requir- Side View of a Unilateral Laceration ; such a 

ing no treatment. laceration may cause abortion in the latter 

months of pregnancy. 

ance of an erosion, and distended glands are more or less 
abundant. Out of the cervical canal exudes a glairy or muco- 





Side view of a Bilateral Laceration, re- Front View of a Bilateral Laceration, show- 
quiring treatment. The lips are ing eroded area and Nabothian folh- 
everted, and the Nabothian follicles cles. 
stand out as prominent papillae. 

purulent secretion, which continually irritates the ulcerated part 

and prevents it from healing ; in fact it has in the beginning been 

Fig. 108. Fig. 109. 





of approximating the lacerated lips, 
demonstrating the true condition. 



the origin of the ulceration. On catching the anterior and posterior 
margins of the cervical lips in two tenacula and attempting to draw 



234 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

them together, it is at once evident that there is a laceration with 
well-defined lips, which are deeply infiltrated. As the lips are 
drawn together the erosion in the centre is turned in and disappears, 
showing that it is a part of the mucous membrane of the cervical 
canal. In other words, the condition is that of a lacerated cervix 
with everted and eroded lips, that condition so frequently mistaken 
in the past for ulceration of the cervix. This third class of cases 
is the only one demanding treatment. 

It is an undoubted fact that the majority of cases of cancer of 
the cervix occur in women who have borne children and have a lace- 
rated cervix. It is also undoubtedly true that cancer of the cervix 
uteri occasionally occurs in nulliparous women. The only reason 
for the surgical treatment of the first two classes would be the fear 
that any ulceration of even small degree would have a determining 
influence on the development of cancer. This fear is, however, not 
so well supported by facts as is generally supposed. 

Laceration of the cervix is frequently associated with subin- 
volution of the uterus and pelvic venous stasis. Leucorrhea, dys- 
menorrhea, aches and pains, a feeling of weight and bearing down or 
dragging referable to the pelvis, associated with a feeling of general 
weariness are the symptoms generally found in this condition. 

The best method of relieving these associated troubles is by re- 
pairing the cervix, in order to start involution of the uterus, which 
process commonly follows operative procedures on that organ. The 
steps of the treatment consist in the proper denudation of the lips 
and approximation of the denuded surfaces by sutures. Where 
infiltration is very marked the lips cannot accurately be brought 
together, and therefore preparatory treatment is required. 

Preparatory Treatment. — This consists in measures intended to 
deplete and diminish the size of the cervix. Douches of water, 
as hot as can comfortably be borne (110° F.), once or twice daily, 
for from ten to twenty minutes, followed by a rest for an hour, 
are valuable adjuvants. The cervix must be exposed by a bivalve 
speculum with the patient in the dorsal position. Depletion is then 
obtained with a fine knife, opening as many distended follicles as 
can be seen. From four to eight drachms of blood should be drawn 
once or twice a week. By following each depletion with a 50 per 
cent, boroglyceride tampon, left in for twenty-four hours, the cervix 
in from three to six weeks will be reduced in size and quite flaccid, 
and in a favorable condition for the plastic operation. 



LACERATIONS OF THE SOFT FARTS. 



235 



Operation. — As a preliminary step it is absolutely necessary to 
make sure by a bimanual examination that there is no inflammatory 
disease of the pelvis involving the ovaries and Fallopian tubes. 
The patient is then placed in the dorsal position, with the buttocks 
on the perineal pad and the thighs held well flexed on the abdomen' 
by the leg-holder. The cervix is exposed by retracting the poste- 
rior vaginal wall with a Sims speculum, and the anterior and poste- 
rior lips are caught by bullet forceps and drawn down toward 
the vaginal orifice. A constant irrigation of the field of operation 
is kept up throughout the whole procedure. Drawing the cervix a 

t, „„ Fig. 11J. 

Fig. 110. 



"SSi 




"''=S \""\ 




1 


,■::,', 


fe 


! 


"'V;i 


t 
1 


!=^L--. . 




,' ' 


, ; 


; 


'i: 


,i 




\ :"■;:" 


® 




m 


: 




HP 









Incision in the Angles of the Laceration. 



Method of Denudation. 



little to one side, an incision is made in the angles of the tear as 
deep as the denudation on the lips is to be carried. Scar-tissue is 
often encountered in the angles, and the incision must extend below 
this, into healthy tissue. 

From this incision the denudation is carried down, first on the 
posterior, then on the anterior lips, as shown in the diagram, by 
means of a sharp knife. Care must be exercised not to denude too 
much on the vaginal surface, and, on the other hand, to leave a 
small strip of undenuded mucosa in the centre of both lips, which 
strips represent the future cervical canal. Both lips are similarly 
denuded. 

An effort is made in the denudation to go through the cicatricial 
into the sound tissue everywhere, and to make such denudations as 
will when approximated secure a conical cervix with a small external 
os to project into the vault of the vagina. 

No fear need be entertained of wounding the circular artery. 
Any vessel which is divided during the operation will be controlled 
as soon as the sutures are introduced. 

The sutures are of silkworm-gut and fine silk or catgut ; the 



236 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY 



former used at the points of greatest tension, and the latter when 
necessary to secure accurate superficial union between the tense deep 
sutures. 

A small stout curved needle with its carrier is grasped in the 
needle-holder and a strand of silkworm-gut hooked into the loop. 
The operator, while the lips are drawn well apart by his assistants, 
introduces the needle just above the angle of the incision, on the 
vaginal mucosa, and with a sweep brings it out in the cervical canal 
high up. It then crosses the canal to a corresponding point, re-en- 




Fig. 113. 




Silkworm-gut Sutures in place on one side, ready to be tied ; front and lateral views. 



ters the tissue, and reappears on the vaginal mucosa of the opposite 
lip, at a point opposite and corresponding to the point of entrance. 
A second suture is passed, in like manner, a little lower down on 
the lips, and often a third near the point. These sutures are left 
loose and clamped in a pair of artery forceps, while the sutures of 
the opposite side are introduced in like manner. 

There are two ways of securing sutures so as to hold the lips 
snugly together : they may simply be tied in a square knot, or they 
may be held in place by running a perforated lead shot down, 
and pushing it up on the suture until the lips are drawn closely 
together, when the shot is squeezed and allowed to remain in place. 
When the vaginal outlet is operated upon at the same sitting, it will 
be easier to remove the cervical stitches if the shot are used. It is 
not necessary to observe such great care in removing all blood-clots 
from the angle of the wound before approximating, as has been 
generally supposed. 

The uppermost sutures are tied first, and then in succession the 
other ones. Any pouting between the sutures should be disposed 



PLATE XVII. 






the knife ; c. the denuda- 



tion has been a< uiplished ; I), sutures introduced ; /•.', completed, operation. 



LACERATIONS OF THE SOFT PARTS. 237 

of by introducing superficial sutures of fine silk or catgut between 
the silkworm-gut. 

Fig. 114. 




Silkworm-gut Sutures in Place, tied on the right and shotted on the left side ; intervening 
Approximation Sutures of fine silk. 

The vagina is washed out after the operation, and a loose iodo- 
form gauze pack applied, which is left in place five or six days. 
The vulva is protected with sterilized cotton and a T- bandage. 

It is not necessary for the success of the operation, so far as 
securing a good union is concerned, that the patient should remain 
in bed ; it is, however, important in a certain class of run-down 
patients, for the sake of their general good condition and to make 
an impression on their nervous system, that they be kept in a 
recumbent position for two or three weeks. This combination of 
the rest cure with the operation is so important that it may well be 
doubted in many cases if the rest has not been the most important, 
if not the sole factor in the recovery. 

Catheterization need only be practised when the patient is unable 
to void her urine. The bowels should be opened at least every other 
day by mild purgative medicines or by enemata of soap and water 
or oil and water. 

The stitches should be removed in from three to six weeks; when 
the vaginal outlet has been operated upon, they should be allowed 
to remain two or three months undisturbed, to avoid dilating the 
outlet in their removal. They are best removed by placing the 
patient in the side position and retracting the posterior vaginal wall 
until one of the sutures is seen ; this is caught by a pair of forceps 
and drawn down until its loop is exposed, when it is cut and the 
suture drawn out. It is important after all have been removed to 
make a digital examination in order to verify the fact. Sexual 
relations should be forbidden for three months. 



238 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

Incomplete Ruptuke of the Recto- vaginal Septum. 

Recent. — Recent incomplete ruptures of the recto-vaginal septum 
appear as furrows in one or both vaginal sulci, extending down to 

Fig. 115. 




Virginal Vaginal outlet. 



the posterior comissure and involving the skin perineum as far back 
as, but not including, the sphincter ani. These furrows are made 
by the child's head or shoulders in passing through an outlet either 
relatively too small or through one whose tissues are not sufficiently 
elastic, or, again, in entering the outlet in a faulty position. The 
forceps are a frequent factor in the production of these injuries. 
Shallow tears of this character may be neglected, and if the parts 
are not infected during the puerperium their natural apposition 
will generally be sufficient to ensure a partial primary union, pro- 
vided injections have not been given during the convalescence, 
and union prevented by the nozzle of the syringe entering into 
and separating the lips of the wound. Hemorrhages following 



LACERATIONS OF THE SOFT PARTS. 239 

these lacerations are not often serious, but are at times exceed- 
ingly annoying. 

Tears extending half an inch down into the tissue should be 
repaired at once ; that is, within the first twenty-four hours. It 
is a common but serious error to estimate the amount of injury by 
a superficial examination of the external parts. This is insufficient, 
as the worst part of the tear usually lies concealed within the vagina, 
and can only be disclosed under a good light and by separating the 
labia and walls of the lax vagina by two fingers. 

The process of suturing is simple. As the natural tendency of 
the tissues is to lie in apposition, but few sutures are necessary to 
assist nature in the repair, and the eye will at once detect the tissues 
to be held together by sutures. It is well during their introduction 
to control the uterine discharges by a tampon of iodoform gauze 
placed loosely against the cervix. Two or three silkworm-gut su- 
tures are sufficient to close a long vaginal rent. The first one should 
be introduced at the upper angle of the tear on the side toward the 
median line of the vaginal floor, and passed well down to the bottom 
of the sulcus, where it is brought out. It is reintroduced at a point 
near its exit, and is carried up and brought out at a point on the 
mucous membrane of the pelvic side of the laceration directly 
opposite the point of original entrance. On the skin surface two 
or three superficial or half-deep silk sutures will complete the ap- 
proximation. A dry powder of boric acid or boric acid and iodo- 
form (7:1), and a loose vulval pad of absorbent cotton, complete 
the dressing, which should be renewed frequently for the first few 
days. In eight or ten days all sutures may be removed, and, in the 
absence of sepsis, the union will be perfect if the sutures have been 
well applied. 

Old Incomplete Tear. 

Relaxation of the Vaginal Outlet. — If a recent incomplete tear 
is neglected, there may be one of several results : a complete union, 
which is unfortunately rare, may occur throughout without inter- 
ference. A partial union may take place at the bottom of the tear 
while the upper part granulates and cicatrizes : the cicatricial 
contraction in such a union may be sufficient to compensate for 
the deficiency created by the tear. Finally, the result of such an 
injury is a permanent deficiency at the introitus, resulting in a 
relaxed outlet, from which the vaginal walls become more and more 



240 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



everted, forming cystocele and rectocele in the erect position, and 
from straining efforts, until finally in some cases the bladder, 
cervix, and uterus escape, a prolapse following as the result of the 
relaxation. 

A relaxed vaginal outlet is recognized by the flatness of the crease 
between the buttocks in front of the anus. Often, a series of con- 




Relaxed Vaginal outlet as seen in the dorsal position. 

centric wrinkles surround the entrance of the vagina, which is 
dropped back nearer the anus. The commissure of the labia may 
be entirely uninjured, or it may be torn down to the sphincter, and 
replaced by a pit of scar-tissue. This latter fact in no way influ- 
ences the condition. 

On separating the labia on either side with the fingers, the out- 
let presents an everted, gaping appearance, and on testing it with 
the fingers, its structures are found lax and incapable of resistance. 
The cervix is readily exposed by making a speculum of the fingers 
to push back the anterior and posterior vaginal walls, and the 
uterus is quite often found retroposed and in descensus. 

The direction of the outlet in cases of relaxation is characteristic. 
Normally, it points downward and backward toward the end of the 
sacrum, while here its direction is toward the promontory or into 
the abdomen. 



LACERATIONS OF THE SOFT PARTS. 



241 



The symptoms occasioned are numerous and in direct relation 
to the lesion. There is a feeling of pressure, of dropping out, of 
something protruding, and of discomfort on walking, the patient pre- 
ferring the sofa; there is backache, and a dragging sensation, due 
to the increasing displacement of the uterus. Leucorrhea and all 




Appearance of Relaxed Vaginal Outlet in Sims's Position. 

the symptoms of endometritis are apt to supervene. The bowels are 
constipated, as the expulsive efforts are wasted on the outlet, the 
sphincter ani muscle forming the greatest point of resistance. Nerv- 
ous symptoms, referred to the stomach and head, are but expressions 
of the general loss of tone. 

The treatment of this condition is by a resection of the outlet 
and both sulci in a similar manner to the Emmet operation. The 
denudation includes the posterior two-thirds of the outlet and ex- 
tends up each sulcus in the form of a triangle. It is unnecessary to 
extend this denudation on the outside, beyond the ring of the hymen 
or its broken remains, but it should be carried not less than an inch 
or an inch and a quarter up each sulcus, and frequently even more. 
It is best to outline the area to be denuded with the point of a knife. 
Two points in the hymeneal ring on opposite sides are caught with 
curved tenacula between a half and three-quarters of an inch from the 
urethra, These points are represented by the lower caruncles or rem- 
nants of the hymen, and when drawn together will show the size of 



242 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY 




the area to be denuded. 

sulci a tenaculum is to be introduced 

Fig. 119. 



the repaired outlet, due allowance being 
made for future relaxation. The rectocele 
is now caught up by a tenaculum at a point 
nearest the vulva which is most easily lifted 
up to or near the urethra. By dragging 
slightly on these three tenacula the vaginal 
tissues will be so thrown into ridges as to dis- 
close a deep sulcus running up the vagina on 
each side of the rectocele toward the cervix 
uteri (Fig. 119). These sulci represent the 
original tears, and were produced by the 
levator ani muscles and fascias retracting to 
the pelvic walls after being torn from their 
At the extreme end 
(toward the cervix uteri) of both these 
nto the tissue in the depths 




Fig. 120. 



The rectocele la seized with the tenaculum 
at a, ami is drawn I" the right, cx- 
posing i in' lefl \ aginal sulcus, a, b. c, 

which iimsl l)i' denuded. The point 

h should be secured with a tenacu- 
lum Im lure denuding. 




of the sulcus : these points may be a half inch, they may be two 
inches, from the vaginal outlet. Five tenaculi are now in place — 



LACERATIONS OF THE SOFT PARTS. 



243 



one on each side of the vaginal outlet at the lowest points repre- 
sented by the remnants of the hymen, one at the uterine end and 
in the depths of each sulcus, and one in the crest of the rectocele. 
These five points may now be joined together by straight incisions 
made with the point of a knife, drawn first from the tenaculum 
in the crest of the rectocele to each of the tenaculi in the depths 
of the sulci, then from these two tenaculi (in the depths of the 
sulci) respectively to the tenaculi which catch up the caruncles 
(remnants of the hymen). Finally, the two tenaculi catching 
Fig. 121. p IG . 122 . 





'Tile li'ft sulrll- (IrllUiln!. 



Both Milci ilenuiU'd. 



up the caruncles are joined together by a U-shaped incision run- 
ning from one tenaculum down, around the posterior commissure of 
the labia, to the tenaculum on the opposite side, care being taken to 
keep the incision well within the mucous membrane and not too 
encroach upon the skin. The incisions would appear diagrammati- 
cally as shown by Fig. 123. All the mucous membrane included 
between these preliminary tracings is to be denuded. The denuda- 
tion is rapidly made by catching up the tissues with dissecting 
forceps within the limits of the marking, and cutting it off in long- 
strips with scissors curved on the flat (Fig. 120). Bleeding vessels 



244 



AN AMERICAN TENT-BOOK OF GYNECOLOGY. 



rarely require tying, as the sutures introduced immediately after 
the denudation control all hemorrhage (Figs. 121 and 122). 



Fig. 123. 




V-shaped Suture introduced and ready to be tied. 

Sutures are introduced to bring the sulci together, and the first 
suture of silkworm-gut is placed about a third way down the right 
sulcus from its upper (uterine) end, entering and emerging on the 
vaginal mucosa close to the incision. The suture is introduced in 
the mucous membrane on the rectocele, carried down through the 
tissues to the depth of the sulcus and toward the vulva, where it 
emerges at a point half an inch nearer the vulva than its entrance ; 
it is reintroduced as near its point of exit as possible, and carried 
through the tissues backward and upward to emerge through the 
mucous membrane on the pelvic side of the sulcus at a point directly 
opposite its original point of entrance on the rectocele. This consti- 
tutes Emmet's V-shaped suture (Fig. 123). At the bottom of the sulcus 





V-shaped suture tied, and Superficial 
Catgut Sutures in place. 



Sutures tied on Right and in place, ready- 
to be tied, on Left Side. 



the suture appears at a point lower down toward the vulva than 
either the point of entrance or emergence. The suture, which is 
tied at once, drags back toward the cervix uteri the lower vulvar 



LACERATIONS OF THE SOFT PARTS. 245 

part of the denudation and holds it there ; it also serves as a tractor 
in bringing down the denuded area above, thus facilitating the intro- 
duction of the remaining sutures. 

The silkworm-gut suture is tied, and the approximation above 
toward the cervix uteri is made perfect by three or four fine catgut 
sutures, each of which must sweep well under the tissue, the last 
one being introduced at the angle (extreme or uterine end of the 
sulcus) to prevent hemorrhage from the vessels cut during the denu- 
dation. In the opposite sulcus silkworm-gut and catgut sutures are 
placed in a similar manner (see illustrations). 

The wound area is now reduced to a shallow pit, representing the 
lower or vulvar end of the denudation in the sulci, on each side of 





Sutures of both Sides tied, and the Crown Suture, together Completed Operation, 

with one Superficial External Suture, in place. 

the central undenuded tit (crest of rectocele), and the more ex- 
ternal parts of the denudation (Fig. 126). 

One or two additional V-shaped sutures placed in each sulcus pro- 
gressively toward the vulva now almost completely close this whole 
area (Fig. 129). To complete the operation a silkworm-gut suture is 
introduced, gathering together the three original points represented by 
the tenaculum at the crest of the rectocele and the two tenaculi at the 
caruncles (Fig. 132). The suture is introduced into the mucous mem- 
brane inside the labia minora of one side, close to the denudation, 
and is carried under the lower caruncle, emerging in the denuded 
area close to the mucous membrane edge ; it is then carried under 
the tenaculum in the crest of the rectocele, at a point far enough 
forward to avoid pulling on the rectocele when tied, and is then car- 
ried in a similar manner under the caruncle on the opposite side, 
emerging at a point corresponding to its original point of entrance. 
The points to be approximated by this suture (the so-called crown 



246 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

Fig. 129. 




Introduction of the sutures. The point 
of the emerging needle is held by the 
tenaculum. 



Fig. 130. 





Both sulci are closed. The support of the 
perineum is restored. The posterior 
wall of (he vaginitis brought forward. 

The reclbeele is cured. 



LACERATIONS OF THE SOFT PARTS. 



247 



stitch) are represented in Fig. 126, by P, P, P. By drawing these 
points together with the suture the wound is contracted to a 
superficial area which can be readily approximated by a few super- 
ficial external silk sutures. On tying the crown stitch all previ- 
ously placed sutures disappear from view into the vagina, for the 
reason that the denudation has been almost entirely within the va- 
gina (on the pelvic floor) where the laceration originally occurred. 
The stitches have been introduced well within the vagina and have 





4:0 




Sutures for closing the superficial perineum 
and fourchette. The anterior suture is 
called the " crown suture." 



Emmet's operation of perineorrhaphy 
completed. Compare this figure 
with that representing the con- 
dition of the parts before opera- 
tion (Fig. 119). 



been so placed as to drag all the relaxation into the canal from which 
it originally came (Figs. 133 and 134). 

Rupture of the Recto-vaginal Septum. — In complete rupture of the 
perineum the septum between the genital and the alimentary canals 
is broken down for a variable distance, and both possess a common 
outlet. The tear extends from the posterior commissure of the labia 
back through the perineum and the sphincter muscles into the rec- 
tum and for a variable distance up the rectum and vagina. This 
injury may vary from a superficial tear, barely involving the 



248 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



sphincter muscle, to a rupture extending one or more inches up the 
septum toward the cervix. 

Fig. 134. 




Speculum introduced into the Vagina, showing the result of the operation. 



One of the commonest causes of rupture of the recto-vaginal 
septum is rapid delivery of the child's head with forceps, thus 
bringing the head down upon an insufficiently relaxed outlet, and 
substituting a hasty delivery, accomplished during a few pains, for 
nature's slow equable dilatation attained only after a great number 
of descents of the head, each time wedging the orifice a little farther 
open. The rupture in these cases begins at or within the posterior 
commissure, and extends rapidly back over the skin perineum, and 
through the sphincter into the anus and up the septum. A head, 
unusually large, or one which has not been susceptible to moulding, 
or one persisting in the occipi to-posterior position, are all frequent 
occasions of this injury. 

The immediate dangers from sepsis are great in these cases, as 
in all difficult labors involving delay, because of extensive injury to 
the soft parts, more or less prolonged manipulation, and especially 
the subsequent constant contamination of the lacerated area by fecal 
discharges. 

Symptoms. — The common symptom is incontinence of feces 
and flatus. Where the rupture has merely extended through 
the sphincter or but a short distance beyond, it is possible for the 
subsequent contraction of the scar-tissue, forming between the two 
ends, to so bind them together and give the sphincter muscle a point 
cVappui, that it will remain functionally active and no feces will 



LACERATIONS OF THE SOFT PARTS. 



249 



escape, and sometimes the patient will control even the flatus. It 
is important to recognize this fact, as writers have positively asserted 



Fig. 




Normal Sphincter ; no break in the continu- 
ity cf the circular fibres. 



Fig. 136. 




Slight Solution of Continuity in the Sphincter 
filled in with connective tissue. No im- 
pairment of function. 



that with every tear of the sphincter its function is necessarily 
abrogated. We must be prepared, therefore, to meet lacerations of 
all degrees — shallow tears in which the sphincter's function is not 
apparently interfered with, those which are deeper but in which 




Solution of Continuity imperfectly bridged 
over with connective tissue. Partial loss 
of function. 



Fig. 138. 




Sphincter completely Ruptured. Divided, ends 
being widely separated. Complete loss of 
function. 



some control of feces is still retained, and still others in which there 
is a complete tear resulting in absolute incontinence, the flatus 
escaping and the patient soiling herself as soon as the desire for 
evacuation is felt. 

Treatment. — The only successful plan of treatment is reunion 
of the torn surfaces by suture. Such an expectant plan as binding 
the knees together and restraining the patient's movements after 
confinement, is to be rejected as worthless. In all these cases the 
immediate operation is called for within twenty-four hours after the 
labor. If performed aseptically, this operation will generally be 
successful. 

The Immediate Operation. — If the patient has been greatly 
exhausted by the confinement, or if the physician is not prepared 
to perform the operation properly at that time, he may delay six. 
twelve, eighteen, or even twenty-four hours, before proceeding to 
unite the tear. The operation may be performed at once or after 



250 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

the patient has had a refreshing nap and some stimulation admin- 
istered. She is laid transversely across the bed with the hips rest- 
ing on the edge on a perineal pad, which drains into a bucket. If 
the bed has a spring or woven-wire mattress, and the centre sags so 
much as to prevent free drainage, a board similar to the fracture- 
board used in hospitals should be inserted beneath the springs. It 
is not necessary to give an anesthetic unless the patient be so nerv- 
ous as to be unable to control herself, as a traumatism which has 
been sufficient to cause the rupture will also produce partial anes- 
thesia of the soft parts by pressure. A little moral suasion by the 
physician will often quiet a nervous women sufficiently to secure her 
intelligent co-operation during the operation. The patient will some- 
times be able to hold her own legs flexed upon the abdomen, by 
placing one hand under each knee, but it is always better to employ 
some form of leg-holder, if at hand, as it relieves her of the tension. 
The leg-holder described in the chapter on Technique is the one 
which is best employed. A competent nurse or assistant with clean- 
washed hands stands by the operator ready to assist. 

The vagina and external parts are prepared as is usual for 
plastic operatious. The surgeon takes his seat in front of the 
patient, so that his shoulders are almost on a level with the 
vulva. His instruments are spread out in an orderly manner 
on a low table to his right, on a clean sterilized towel, or in a 
tray, covered with hot water. To his left is placed a basiu of 
warm water for occasional cleansing of his hands. An irrigator 
containing two quarts of water at a temperature of .about 110° F. 
hangs back of him three feet above the level of the bed. 

As the operator separates the labia with his left hand, the 
assistant directs the water on the parts which at the same time 
he gently sponges with pledgets of absorbent cotton. 

The extent of the tear into the rectum and up into the vagina 
must be carefully noted. Ragged tits and tissue which resemble 
large blood-clots must be trimmed off evenly with a pair of sharp 
scissors. 

The uext step in the operation may properly be called the 
reduction of the compound and complicated laceration to a simple 
form of tear, by closing the rectal part of the rent. This is accom- 
plished by passing a number of interrupted catgut sutures, begin- 
ning at the angle and extending down to and including the ends of 
the sphincter, each entering and emerging on the torn rectal mucous 



LACERATIONS OF THE SOFT PARTS. 251 

membrane and penetrating the septum one-eighth of an inch, which 
is deep enough to secure a firm hold. These sutures are then tied 
from above downward and the ends dropped into the rectum. 
There then remains but the edges of a deep perineal and vaginal 
tear to be approximated. This is repaired by deep sutures of silk- 
worm-gut, beginning in the vagina at the upper angle and passing 
down over the commissure on to the perineum and to the anus. 
Each suture extends to the bottom of the tear. They are tied 
from above down, as introduced. 

The lowermost external suture must enter and emerge well 
behind the divided ends of the sphincter, sweeping deeply around 
in the septum, thus binding the sphincter ends firmly together. 
About four silkworm-gut sutures to the inch are sufficient. The 
patient should lie quietly in bed, but she need not be restrained 
from turning over gently or lying on her side. The bowels, instead 
of being locked, should be opened freely on the second day by 
a laxative, followed, if need be, by an enema given with extreme 
care. If an enema be ordered, careful directions as to the intro- 
duction of the nozzle of the syringe should be given to the nurse, 
as great injury may be done by its careless use. The nozzle should 
be introduced gently, passed back toward the sacrum, and then the 
contents of the syringe slowly injected. After the bowels are 
opened, a mild laxative should be administered every day or so, 
as the fecal discharge must be kept soft and straining at stools pre- 
vented. The vulval orifice and the perineum should be well 
sprinkled with iodoform and boric-aid powder (1 : 7) and protected 
by a pad of sterilized absorbent cotton loosely applied and renewed 
three or four times daily. In eight or ten days the stitches should 
be removed with the patient in the same position as at the operation. 
The sutures are removed by drawing each to one side and cutting- 
its loop, and then by pulling it toward the side on which the loop 
is cut. 

The Intermediate Operation for Complete Tear. — During the 
process of granulation and formation of the cicatrix the wound of 
a complete tear presents essentially different conditions to the ope- 
rator from those found either immediately after the reception of the 
injury or later in the secondary period, when the scar-tissue has been 
fully formed. From the seventh to the fourteenth days the wound- 
area is covered with delicate friable granulations, and its margins 
are marked by pink lines, which contract until finally only a linear 



252 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

scar remains. The operation at this stage may be performed with 
ease, and is followed by good results. The patient is brought, as 
before, to the edge of the bed and the parts thoroughly sterilized. 
A pledget of cotton saturated with a 10 per cent, solution of cocaine 
hydrochlorate is laid over the whole lacerated area. In ten minutes 
the operator may take his seat in front of the patient, and with his 
thumb in the rectum and his finger in the vagina draw one side of 
the torn area into view and thoroughly denude it down to healthy 
tissue by scraping off all the granulations with a sharp scalpel. 
The older the wound the greater will be the difficulty of denuding 
its margins properly, and in some cases a sharp pair of scissors will 
be necessary to complete this part of the denudation. A freely- 
oozing surface with sharp margins is now exposed. The sutures are 
then passed as in the immediate operation. 

Secondary Operation for Complete Tear. — The secondary opera- 
tion is performed at any time after the formation and contraction of 
the scar-tissue are completed. It must be remembered, as it bears 
an essential relation to the denudation to be made, that the area of 
scar-tissue at this stage by no means represents the area of the 




Rupture of the Recto-vaginal Septum: Ends of the denuded sphincter shown at the sides of the rectum. 

original injury. The broad primitive wound-surface has contracted 
down into narrow lines more or less > <-shaped, the lower ex- 
tremities representing the position of the sphincter ends, the upper 
the commissure, and the transverse bar the lower margin of the rec- 
to-vaginal septum. The denudation must, therefore, be made to 
cover an area widely exaggerating the outlines of the scar-tissue. 
The sphincter area is generally characterized by a shallow pit, 
often marked by little dimples at either extremity of the septum, 



LACERATIONS OF THE SOFT PARTS. 25-i 

which presents a more or less sharp border, and beneath which pout 
a few tits of the deep-red rectal mucosa. Not infrequently this 
pouting is considerable, and has often been mistaken for hemor- 
rhoids. 

Before making the denudation the outlines of the area to be 
denuded must be mapped out with the point of a scalpel. This 
allows a rapid denudation to be made, without the error to which 
one is liable in making a free-hand denudation with the scissors alone. 
The first line may be made around the septum, splitting it at the 
rectal margin, and including both sphincter ends; this line is con- 
tinued up on each side in a curve, convex backward to the nymph se ; 
from this point lines on both sides sweep into the vagina, along the 
lateral walls, until they meet in a point up in the vagina a half inch 
or more above the tear in the sej)tum (Figs. 140 and 143). 

The denudation is rapidly made with a pair of curved scissors 
and a tenaculum or rat-toothed forceps. The lower parts should 
be denuded first, so that that which follows is not obscured by the 
blood. The tissue is removed in long strips until the whole area 
is thus freshened. 

The sutures are introduced much as described in the immediate 
operation. First, interrupted catgut sutures closing the rectal side 
of the tear from the angle down to the sphincter, radiating out on 
to the skin surface. The ends of the sphincter muscle are thor- 
oughly exposed until muscular fibres are plainly visible. A tenacu- 
lum is hooked into each end of the muscle and the two ends brought 
together. A small catgut ligature is thrown about each end of the 
muscle and the free ends of the catgut securely tied. The muscle 
ends are thus surely approximated with no possibility of any other 
tissue coming between and preventing their union. The ends of 
the sphincter muscle are held together, and the catgut relieved of a 
tension it cannot stand by two silkworm-gut sutures introduced on 
the skin surface well behind one of the divided ends of the sphincter, 
passing directly through the end of the muscle itself, sweeping up 
around the septum-tear into the vagina, to emerge in the vaginal 
septum at a point well above the upper end of the septum-tear. 
The sutures are reintroduced at a point a slight distance from their 
point of exit, carried down the vaginal septum on the opposite side 
of the septum-tear, pass through the torn end of the sphincter and 
emerge on the skin surface at a point directly opposite that of 
their original entrance (Fig. 141). 



254 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



The remaining sutures are passed, beginning at the upper angle 
of the denudation in the vagina, by introducing silkworm-gut 




Rectal Sutures in Place, also supporting sutures passing through ends of Sphincter Muscle. 

sutures about four to the inch, and extending from the vaginal 
mucosa down to the bottom of the septum. These sutures enter 
and emerge on the vaginal mucosa. They extend seriatim from 

Fig. 141. Fig. 142. 





Rectal Sutures Tied, and Sutures supporting 
ends of Sphincter Muscle in place; also 
Vagina] Sutures. 



Sutures within the Vagina Tied; external or 
slcin Sutures in place, lowermost one passing 
through end of Sphincter Muscle; support- 
ing suture tied. 



the upper part of the vaginal denudation down over the commissure 
on to the skin to the lowest point (near the rectum) of the denuda- 
tion. The lowest of these sutures is made to pass well behind and 
through the ends of the sphincter muscle, giving additional support 
and security against retraction (Fig. 142). 



LACERATIONS OF THE SOFT PARTS. 



255 



Before beginning the denudation it is necessary to first thoroughly 
stretch the sphincter, with the object of elongating it as much as 
possible, and to prevent its spasmodic contractions the first few days 
following the operation. When the operation is completed the parts 
should be sufficiently relaxed to allow of the easy entrance of the 

Fig. 143. Fig. 144. 




Fig. 143.— Denudation and sutures for repair of laceration. The two posterior sutures pass through the 

sphincter muscle. 
Fig. 144.— Completed operation. The anal opening is surrounded by the sphincter. One shot has dis- 
appeared in the anus. The anterior suture is omitted. 

little finger. Should the new sphincter be so tight as to make this 
in any way difficult, the operation will almost inevitably fail unless 
the tightness is at once overcome. A small tenotomy knife may be 
introduced through the skin directly over the posterior edge of the 
sphincter muscle, and its fibres divided by subcutaneous section to 
an extent to allow of stretching the sphincter sufficient for the easy 
introduction of the finger into the rectum. The most prolific causes of 
failure of this operation are neglect to secure proper stretching of the 
sphincter muscle and accurate approximation of the muscular ends. 
After the completion of the operation the urine should be drawn, 
the vagina cleansed of blood and dried out with pledgets of absorb- 
ent cotton, iodoform and boric-acid powder sprinkled over the sur- 



256 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

face and between the lips of the vulva, and a pad of loose absorbent 
cotton laid between the thighs and held in place by a T-bandage. 
The urine should not be drawn after the operation unless the 
patient is unable to pass it. Each time after urinating the vulva 
should carefully be dried with absorbent cotton, and powder, and 
fresh cotton applied. The bowels should be opened not later 
than the third, preferably on the second day, and should then be 
kept open by a daily evacuation. The patient should take a pur- 
gative pill or saline purge, followed by an enema in six or eight 
hours, if a natural soft movement does not follow. Extreme care 
must be observed in giving the enema not to allow the point of 
the syringe to impinge on the stitches in its introduction. 

It is not necessary to bind the limbs ; on the contrary, consider- 
able liberty of movement may be allowed without separation of the 
legs. The sutures should be removed, as in the preceding opera- 
tions, in from eight to ten days. 



GENITAL FISTULA. 



Genital fistula? are abnormal avenues by means of which some 
portion of the urinary tract or the bowel communicates with the 
genital tract or the exterior of the body. 

Fecal fistulse are formed by a communication between the rec- 
tum or the small intestine, and the uterus, vagina, or bladder. 

Urinary fistulas are formed by a ureter emptying into the 

Fig. 145. 




The Various Forms of Vesical Fistul* ; v, u, vesico-uterine ; v, v, u, vesico-vagino-uterine ; v, v, 
vesicovaginal ; u, v, urethrovaginal. 

uterus or vagina, by the bladder discharging into the uterus or 
vagina, or by an opening from the urethra into the vagina. 



Ureteral Fistula. 
Ureteral fistulse are sometimes congenital, discharging lo\ 



down 



near the external urethral orifice : they commonly arise, however, 
from severe labors in which the laceration has extended through 
the cervix and beyond into the vault of the vagina and out into the 
broad ligament, tearing the ureter, or they follow a vaginal hyster- 
ectomy. After granulation and cicatrization are completed the 



258 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

ureter will be found discharging into the uterus or vault of the 
vagina. 

Diagnosis. — This can be made by watching the os uteri, or the 
small orifice in the vault of the vagina, when the urine will be seen 
discharging at intervals of a few seconds to a minute or more, in small 
jets. The patient complains of a constant discharge of urine, and 
yet she voids the urine which collects from the other kidney at 
regular intervals. The injection of an aniline solution into the 
bladder brings no corresponding discharge from the fistula ; on the 
contrary, its discharges remain clear. Especial care must he taken 
not to be misled in the diagnosis when a vesico- vaginal fistula, con- 
stantly draining the bladder, exists with a uretero-uterine fistula. 
If the ureteral orifice can be seen and a catheter introduced, it 
passes in the direction characteristic of the ureter ; that is, to the 
back part of the pelvis and up toward the pelvic brim, and possibly 
over the brim toward the kidney. The intermittently flowing urine 
can be collected from the outer end of the catheter. 

Treatment. — The cure of a ureteral fistula is a matter of con- 
siderable difficulty, and should only be undertaken by a surgeon of 
considerable skill in plastic work. 

When the ureter empties into the uterus high up out of sight, 
the corresponding kidney has been extirpated by some surgeons as 
the only means within their power of relieving the patient from the 
constant flow. The sacrifice of the kidney, however, is a procedure 
repulsive to the surgeon for the relief of a condition apparently so 
trivial. A better plan is the following : The patient is placed 
in the left lateral or the dorsal posture, and the posterior vaginal 
wall retracted with a Sims speculum. The anterior lip of the 
cervix is caught by a pair of bullet forceps and the uterus drawn 
down. If it is not evident, on account of the deep cervical lacera- 
tion and the scar-tissue, on which side the fistula lies, the cervix is 
split up until the orifice is visible. If the side on which the fistula 
is located can be detected, the cervix is separated for half or two- 
thirds of its extent from the vaginal vault and gradually drawn 
downward. The cellular tissue is slowly and carefully peeled up 
on that side until the ureter is found at the fistulous orifice. 

After freeing the ureter for from a half to one inch out into the 
cellular tissue, it is severed from its uterine attachment, An antero- 
posterior incision is made in the supravaginal portion of the bladder 
about half an inch long. The end of the ureter is cut off quite 



GENITAL FISTULA. 259 

obliquely and turned into the bladder, and the sutures so inserted as 
to retain the ureter in place. The first is passed so as to catch one 
side of the incision except the mucosa, enough of the under wall of 
the ureter to hold it, and the opposite side of the incision. The 
next suture catches the bladder-walls a little more superficially, but 
includes the ureter in the same manner. Each of the following 
sutures proceeding from below upward is passed more superficially 
until the upper limit of the incision is reached. Care must be taken 
not to narrow this part of the incision so as to compress the ureter. 
Two or three superficial sutures catching the bladder-wall and outer 
coat of the ureter complete the union on all sides. The incision 
in the vault of the vagina is then closed by fine silk or silkworm- 
gut sutures, or it may be packed loosely with iodoform gauze. 

Or the abdomen may be opened, the ureter traced from the 
point where it crosses the pelvic brim to its entrance into the uterus, 
liberated at this point, dissected up for an inch, and bladder implan- 
tation performed as described in the chapter on Diseases of the 
Urethra, Bladder, and Ureters. 

Uretero-vaginal fistulas may be closed by passing a sound into the 
ureteral orifice and dissecting up the ureter for about a third of an 
inch, opening the bladder just above the end of the ureter, turning 
its end into the bladder, and closing the incision by sutures on the 
vaginal side. 

Another method is to open the bladder close to the ureteral 
orifice, and pass a catheter through the urethra and bladder and 
through the opening into the ureter. The short portion of the 
catheter visible in the vagina is then shut in by an oval denudation 
embracing both vesical and ureteral openings. Careful transverse 
union with deep sutures of silkworm-gut and superficial sutures of 
silk then establish the channel of communication between ureter 
and bladder. 

Vesical Fistula. 

Vesico-uterine fistula ; vesico-utero- vaginal fistula ; vesico- vagi- 
nal fistula. 

Vesico-uterine Fistula. — In this form of fistula, there is a direct 
communication between the bladder and cervical canal, so that the 
urine escapes constantly through the os uteri externum. The 
demonstration of the vesical involvement can easily be made by 
injecting a colored fluid into the bladder, when it will be seen to 
escape from the cervix. 



260 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

Treatment. — The musculo-fibrous tissue forming the cervical 
canal has a remarkable tendency to contract and close sponta- 
neously any fistulous opening arising from a severe labor. If, 
therefore, but a short time has elapsed since the receipt of the 

Fig. 146. 



Vesicouterine Fistula. Course taken by trie urine indicated by arrows. 

injury, the operator can well afford to wait a few weeks or months 
until he sees what nature alone will be able to accomplish. 

Persistent fistulse may be closed one of three ways : Where the 

Fig. 147. 




Vesico-utcrinc Fistula divided into two channels by a Septum of Scar-tissue. 



fistula is situated high up in the uterus and the amount of cica- 
tricial contraction in the vagina prevents a proper exposure, the- 
abdomen may be opened in the median line just above the symphy- 



GENITAL FISTULA. 261 

sis pubis, the uterus drawn out of the incision, the peritoneum in- 
cised transversely at the vesico-uterine fold, and the bladder care- 
fully dissected from the uterus until the fistula is reached. The 
bladder should be emptied, the fistula cut through, and the opening 
in the bladder closed by a series of interrupted silk or fine catgut 
sutures, four or five to the half inch, including the whole wall down 
to the mucosa. The edges of the opening in the uterus should be 
freshened and drawn together by a row of interrupted silk sutures. 
After carefully cleansing the field, the peritoneum may be re-attached 
to the uterus, the field of operation entirely concealed, and the 
abdomen closed. 

The second method is the reverse of the first, in that the vaginal 
vault is incised in front of the cervix, and the dissection carried up 
between the bladder and the uterus until the fistula is severed. This 
is closed by a row of interrupted silk sutures through the thick- 
ness of the bladder-wall, exclusive of the mucosa. The uterine 
opening may be left to itself, and a small strip of iodoform gauze 
pushed up, anterior to the cervix and under the fistula. The vagina 
is also loosely packed with gauze, which is renewed in three or four 
days. At the end of a week the pack is left out and a daily vagi- 
nal douche of a warm boric-acid solution given. 

In the third method, where the fistula lies near the vault of the 
vagina the cervix may be split up into the track of the fistula, 

Fig. 148. 




Vesico-utero-vaginal Fistula, in which the posterior lip of the cervix is destroy 



which is freshened from the bladder to the uterine surface. If 
necessary, sufficient cervical tissue should be cut away from the 
sides of this incision, so that the denuded fistula forms the apex of 



262 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

a wedge, and is closed when the sides of the cervix are brought 
together. Two to four silkworm-gut sutures are passed through 
from the vaginal surface of the cervix, and when these are tied the 
fistulous area is efficiently closed. The sutures should be removed 
in about ten days. 

Vesico-utero- vaginal Fistula — In fistulas of this character the 
opening is at the cervico-vaginal junction in front, median, or to 
one side of the middle line. The neighboring cervical tissue is 
cicatricial, and there is usually marked loss of substance. Where 
there is much cicatricial tissue in the cervix, it is best to draw the 
cervix downward and backward and dissect the bladder with the 
fistula free from the uterus, for a short distance above the vaginal 
vault. The fistula should then be treated by making a denudation 
extending from the vesical mucosa out on to the vaginal surface 
about a quarter of an inch broad. 

If the fistula is transverse to the axis of the vagina, the tissue 
above should be brought down to the tissue below by a row of silk- 
worm-gut sutures, entered a short distance off from the denuded 
surface and passing down to the mucosa of the bladder. These 
sutures should be passed about five to the inch. They should be 
brought snugly together without constricting the tissues. Where 
the tissue pouts between these deeper sutures, the work of approx- 
imation may be completed by superficial silk or fine catgut sutures. 
If the long axis of the fistula is in the axis of the vagina, the stitches 
should be passed from side to side. 

Vesico-vaginal Fistula. — A direct fistulous communication be- 
tween the bladder and the vagina is the classical affection, brought 
within the reach of the surgeon's skill by the labors of Sims and 
Emmet. These fistulas arise from protracted labors, in which the 
fistulous part of the bladder has been compressed sufficiently long, 
between the head of the child and the symphysis pubis, to produce 
a slough, which comes away in from three days to a week after labor, 
having the artificial opening. They may also arise from direct injury 
of the tissue while using the forceps ; they are more often the con- 
sequence, however, of the want of the forceps to obviate the delay. 
They have also followed unsuccessful operations of the surgeon on 
ihe anterior vaginal wall. 

These fistulas vary in size from a pin-point to one or two inches 
in diameter. The small ones are often the remains of an unsuccess- 
ful attempt to close a larger fistula. In form, a vesico-vaginal fistula 



GENITAL FISTULA. 263 

is round, oval, or irregular. One of the most important complica- 
tions of the condition is a cicatricial contraction of the vagina and 
the presence of cicatricial bands extending from the fistula out on 
to the vaginal walls. 

Teeatment. — When the vagina is contracted by scar-tissue, this 
must be divided in one or more places and so stretched as to afford 
an ample exposure of the fistula. The attempted closure of the 

Fig. 149. 




Vesico-vaginal Fistula ; bladder adherent to the uterus along the darkly-shaded line. 

fistula will succeed in direct ratio to the satisfactory exposure, which 
allows every step of the operation to be accurately conducted. 

If the vagina is eroded and coated with phosphatic concretions, 
this must be relieved by weak warm boric-acid douches — about a 
teaspoonful to the quart — and the erosions are touched occasionally 
with a solution of nitrate of silver, about 5 or 10 grains to the ounce. 
The operation can most conveniently be performed with the 
patient in the lithotomy position, with well-flexed thighs held 
up on the abdomen by a leg-holder, and with the buttocks rest- 
ing on the perineal pad for drainage. The posterior vaginal 
wall is then retracted with a Sims speculum. The denudation 
of the margins of the fistula is made by marking with a sharp 
tion of the margins of the fistula is made by marking with a sharp 
knife the outer limit of the area to be denuded, from a quarter to 
an eighth of an inch from the edge of the fistula. With a fine 
right-angled tenaculum or with a pair of long fine rat-tooth forceps 
the operator catches hold of a piece of the tissue thus outlined, 
lifts it up a little, and proceeds to denude the whole down to the 
mucous membrane of the bladder. The denudation may be accom- 



264 



AN AMERICAN TEXT- BOOK OF GYNECOLOGY. 



plished with a sharp small-bladed knife, but it will more easily 
be made by means of a long pair of scissors, with delicate blades 
that come to a sharp point, and are slightly curved on the flat 
surface. No undenuded islets of tissue should be left to interfere 
with the union after approximation. The direction in which the 
tissues should be brought together depends upon the form and the 
size of the fistula. In the case of small fistulaB it is immaterial ; in 
circular fistulaB the vaginal tissue yields most readily in drawing the 
upper border down to the lower, shortening the vagina, and placing 
the scar across its axis. A long, oblique fistula should be approx- 
imated in the direction of its long axis. The edges of a round 
fistula cannot be accurately brought together, and it often becomes 
necessary to dissect out a V-shaped piece at each end of the fistula, 
thus rendering the opening elongated and its edges easy of approx- 
imation. Two sorts of sutures should be used in approximating 
the denuded margins— silkworm-gut for the deep, and fine silk for 
the superficial stitches. 

The sutures are applied by means of a small curved needle with 
a silk loop as a carrier. The first one may be placed at either end 
or, often conveniently, in the middle. If the fistula is a large one, 
the suture may be tied at once, thus facilitating even closure on both 
sides of it. Each silkworm-gut suture should enter the vaginal 
mucosa from an eighth to a sixteenth of an inch from the edge 
of the denudation, and appear at the margin of the mucous mem- 
brane of the bladder, to re-enter at the mucous margin on the 



Fig. 150. 




Operation for Vcsico-vugiiial Fistula. Stitches introduced preparatory to closure. 



opposite side and reappear on the vaginal mucosa at a point corre- 
sponding with the point of entrance. No suture should penetrate 
the mucous membrane of the bladder where it is liable to become 
the point of a future fistula. Five or six similar sutures to the 
inch should be inserted, and one at or just beyond each angle. 



GENITAL FISTULJE. 265 

These sutures should then be brought together and tied snugly, 
approximating the tissues without strangulation. The pouting tissue 
between these deep stitches can be approximated by fine silk or cat- 
gut sutures. 

The ends of the sutures should be cut about half an inch long, 
and a loose iodoform gauze pack placed in the vagina. Should 
there be any tension whatever upon the sutures, longitudinal incis- 
ions must be made deep in the scar-tissue on both sides of the 
fistulous opening until all tendency to tension is relieved. These 
incisions should be made short, so that they may be closed by 
stitches introduced in the direction of their long axes, thus further 
relieving the tension. This precaution is oftentimes absolutely nec- 
essary to the success of the operation. 

Under no circumstances should a sigmoid or other catheter be 
placed in the bladder for permanent drainage. 

For the first three days the patient should be catheterized every 
three hours, after which she may be allowed to void her urine, 
taking care not to hold it longer than six hours, until the sixth 
day, when she may be allowed to pass the night without waking. 
In the case of small fistulas the patient may void her urine from 
the very first. If the vaginal pack becomes wet or soiled, it should 
be removed at once, otherwise it may be left in place for two days, 
when it is removed and the vagina allowed to remain empty. It is 
not necessary to use a vaginal douche at any time unless there is a 
discharge from the vagina. All the sutures should be removed in 
from eight to ten days. 

Urethral Fistulce. — A fistula following labor and involving the 
urethra is usually small and of its interior half — that part pro- 
jecting into the vagina. Fistulas in the long axis of the urethra 
are at times made artificially by Emmet's operation to relieve vesi- 
cal tenesmus. In closing the fistula, if small, the denudation may 
extend in a circle around it in a manner similar to the vescio-vagi- 
nal fistula ; if large, a wedge-shaped piece may be cut out of the 
under part of the urethra with the fistula at its base, and the denuded 
surfaces brought together by silk sutures, extending down to the 
mucosa and applied closely and with extreme accuracy. 

Fecal Fistula. 

Fecal fistulas are abnormal avenues for the escape of the con- 
tents of the small or the large bowel, either by the vagina or by the 



266 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

bladder. The fistulous orifice, having no sphincter, affords an ave- 
nue for the constant escape of fecal matter when the contents of the 
bowel are fluid. If the fistula is small, opening into the sigmoid 
flexure or rectum, and the contents of the bowel formed, the escape 
of feces occurs but rarely. 

One of the commonest and most distressing symptoms of these 
fistulas is the more or less frequent escape of the intestinal gases, 
which pass out with an audible bubbling or hissing noise, and by 
the evident odor so distresses the patient that finally she entirely 
avoids society and remains at home brooding over her ailment. 

Recto-vaginal Fistula. — Recto- vaginal fistulas are the most fre- 
quent; they consist in a communication between the rectum and the 
vagina through the recto-vaginal septum, at some point between 
the cervix uteri and the vulva. 

Recto-vaginal fistulas in the upper part of the vagina are not 
uncommon sequelae of a cancer of the cervix uteri, and are due to 
a destruction of the upper part of the septum. In most cases 
of this class the disease is already in its last stages, and nothing 
can be done to cure the affection. The duty of the physician 
is limited to keeping the parts as clean as possible by repeated 
irrigations with warm water slightly medicated with boric or car- 
bolic acid. 

Recto-vaginal fistulas in the lower part of the vagina and recto- 
vulval fistulas commonly arise from imperfect union of the tissues 
after an attempt has been made to repair a complete tear of the 
septum. When these fistulas are reduced to the size of a pin's 
head, the closure may be effected by stimulating the tract with 
cantharidis or with a little nitric acid. 

Fistulas may be closed by making a broad denudation, extend- 
ing from the sound tissue, around and deep down into the fistula, 
and then passing sutures, one or two deep, of silkworm-gut, and 
the remainder of silk or catgut, from side to side, just as in a vesico- 
vaginal fistula operation. The sphincter ani should be thoroughly 
dilated so as to render the rectum temporarily incontinent. A loose 
iodoform gauze pack should be placed in the vagina. On the eighth 
day all sutures should be removed. 

When the fistula extends close to the sphincter muscle or is 
bounded on its lower side by a thin band of cicatricial tissue, or is 
very large in diameter, the best course to pursue in its treatment 
usually is to cut through the sphincter muscle and thoroughly 



GENITAL FISTULA. 267 

denude the fistulous area, thus securing snug apposition throughout 
with greater ease and without constricting the tissues. 

The suture and after-treatment of these cases are similar to those 
adopted in cases of complete tear of the septum. 

When the small intestine opens into the bladder at some point 
within the upper pelvic cavity, the only plan of treatment is to 
open the abdomen, find the fistulous tract, and sever the adherent 
intestine from the bladder, taking care, when necessary, to sacri- 
fice rather the bladder than the bowel. This part of the operation 
will usually prove difficult, owing to numerous surrounding adhe- 
sions among the bowels, which must be separted with pains-taking 
care. After loosening the knuckle of bowel from the bladder, 
each viscus should carefully be protected by thick pieces of gauze 
to avoid contamination of the surrounding peritoneum, and the 
openings, first of the intestine, then of the bladder, should be closed 
by sutures. If necessary a portion of the bowel can be excised 
and the ends joined together with the Murphy button. 

The cure of fistula involving different parts of the genito-urinary 
tract requires the nicest kind of judgment and skill. These opera- 
tions are the most delicate and difficult of plastic surgery and are 
not to be attempted lightly. It is only by the most conscientious 
work that satisfactory results will be obtained. 



DISTORTIONS AND MALPOSITIONS. 



Distortions and malpositions of the uterus may result from 
incomplete laparotomies or those in which drainage has been em- 
ployed. Adhesions forming around the drain produce the most 
fantastic twists and bends in the uterus. Neoplasms and diseases 
of adjoining organs also cause flexions and displacements of the 
uterus. But such conditions will not be described here. 

The more common forms of displacement are anteflexion, retro- 
flexion, retroversion, prolapsus, and inversion. It must be borne in 
mind that there is no position of the organ which is normal to all 
women. The uterus is a movable body, varying in its position in 
answer to the condition of the bladder, rectum, and other pelvic and 
abdominal organs. It must not be assumed, because a given womb be 
found with its fundus behind the long axis of the pelvis in a retroflexed 
or retroverted position, or before it in an anteverted or anteflexed 
position, that the symptoms from which the woman is suffering 
come from the womb. Any of these positions may exist, and be 
perfectly natural and normal to a particular individual. 

Pathological Anieoersion is described by some authors, but we 
have never seen a case unless the uterus was displaced by a neo- 
plasm, or adhesions or the distortion of some adjacent organ were 
to blame for the malposition. The uterus naturally follows the 
movements of the bladder, and is generally distinctly and normally 
anteverted when the bladder is empty. 

Pathological Anteflexion. 

This occurs in two chief forms. In simple anteflexion the axis 
of the cervix and the cervix itself occupy a normal relation to the 
vagina. But the body is sharply bent upon the cervix. These 
uteri are found high in the pelvis, drawn up toward the promon- 
tory of the sacrum. The uterus is somewhat fixed in that position, 
downward mobility being limited. The result is that while the 

268 



DISTORTIONS AND MALPOSITIONS. 



269 



woman is erect the entire intra-abdominal pressure falls directly upon 
the posterior aspect of the uterus and the condition is still more 
aggravated. Whether this flexion be due to inflammatory short- 
ening of the utero-sacral ligaments thus drawing up the cervix 
is not proven, but possibly such is the case. The cervix is short 
and fairly well open, but sometimes stenotic. The sound often shows 
the depth of the uterus to be normal and the point of flexure to be 
at the internal os, or the whole organ may be of much decreased 
size (infantile uterus). The posterior wall opposite the flexure is 



Fig. 151. 




Diagram of Pathological Anteflexion arising from contraction of the folds of Douglas : a, direction of the- 
traction of the folds; 6, that of intra-abdominal pressure. 

thinned, while the anterior is thickened. The endometrium is 
usually atrophied and poor in lymphoid elements. This is the 
common picture. But instead there may be marked hypertrophy. 
The cervical canal has lost much of its slit-like form, and is more 
tubular. 

Symptoms. — The patient usually gives some such history as this r 
She menstruates regularly. A few hours before the flow appears 
there is a good deal of pain located behind the pubes, intermittent 
and crampy in character, or continuous, severe, and with spas- 



270 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

inodic exacerbations. A clotted flow appears which affords relief 
for a time. She uses one or two napkins the first day or so, and, 
after lasting two or three days, the flow becomes thin and watery. 
It is followed for a longer or shorter time by a milky discharge 
which is unirritating, but of disagreeable odor. When the patient 
is up she has to urinate frequently, but is not troubled at night. 
Upon examination the uterus is found high up, the cervix small, 
and the fundus is easily detected as a rounded nodule above the 
anterior lip. Rectal examination is exceedingly valuable in that it 
determines the absence of the fundus from its normal position. If it 
is necessary to use the sound, the instrument shows the flexure and 
its degree. Before being passed it should be bent to the apparent 
angle of the flexure, and no force should be used in its introduction. 
Downward traction on the uterus by a tenaculum lessens the degree 
of bend in the uterus and facilitates the introduction of the instru- 
ment. The cervical plug of mucus is opaque and milky or clear, 
seldom purulent. Secondary cervical erosion and inflammation is 
not common. The appearance of the cervix varies greatly in dif- 
ferent cases. Commonly the external os is a rounded hole, and the 
cervix more or less conical. The narrowing of the canal may be so 
marked that a probe is with great difficulty introduced. This is 
of no great diagnostic importance, as it is rare that the outlines 
of the uterus cannot be detected by the bimanual touch. These 
cases are commonly associated with vaginismus in the unmarried 
and with dyspareunia and sterility in the married. 

The other common form of anteflexion is still more interesting, 
and may be designated as anteflexion with retroversion. The body 
of the uterus occupies nearly a normal relationship to the bladder 
and the pelvic walls, or may be somewhat retroverted. The cervix 
is so sharply bent upon the body that its axis is the same as that of 
the vagina. It is always hypertrophied, and may at times even be 
so long as to project from the vulva. The whole organ is somewhat 
lower in the pelvis than normal. This condition is really one of 
hypertrophied cervix bent upon the body, with, possibly, some 
retroposition and descent of the latter. The greater the hyper- 
trophy the more the descent and backward displacement of the 
body. 

Examination shows the enlarged cervix, often with a conical 
end and a circular os externum. The body is not always felt per 
vaginam, but is readily found by rectal examination. 



DISTORTIONS AND MALPOSITIONS. 271 

Because of the elongation of the cervix, together with the flexure, 
introduction of the sound is difficult. The total length of the canal 
is increased, but that of the body is about normal. If the organ 
be pushed high in the pelvis, the cervical elongation apparently 
decreases. The posterior lip is much longer than the anterior. 
The endometrium is the seat of hypertrophic changes, especially 
at the os internum. 

It is an interesting fact that in all these cases of anteflexion the 
bladder is attached to the uterus abnormally high. 

So far, no attempt has been made to explain the pathogeny of 
these two lesions. That simple anteflexion is associated with short- 
ening of the utero-sacral ligaments is undoubted. Whether this 
shortening be congenital or acquired is most often not determined. 
Transverse sections of the child show that the os internum occu- 
pies a position relative to a line drawn from the symphysis to the 
end of the last sacral vertebra, much higher than in the adult. 
If any disease of infancy should decrease the elasticity of the utero- 
sacral ligaments, as the body of the uterus grows, the cervix being 
fixed, the body will fall forward on the bladder. The continuous 
force of intra-abdominal pressure, together with its increase by 
lacing, adds to the natural tendency the uterus has to bend. Also, 
when the organ is gorged with blood at the menses and the woman's 
body erect, with that pressure still more will it tend to bend. 

In infancy the cervix is relatively large, but the hypertrophy 
accompanying certain flexions cannot be accounted for. It is utterly 
unlike any that occurs as the result of inflammation in the adult 
organ. The process is probably begun even before birth or in early 
infancy. Inasmuch as the cervix is first developed, the explanation 
may be found in some stimulus, giving this an impetus too early or 
too strong, resulting in unbalanced growth later on. 

These patients have more flow than those suffering from simple 
anteflexion, and the pain is not so great ; the blood does not clot as 
much. There is the same leucorrhea, and more of it. Backache 
and pelvic tenesmus are often present. Vaginismus and local 
nervous disturbances are common. The married are frequently 
sterile. 

An explanation of the symptoms is here called for. The dys- 
menorrhea is due, not to the obstruction to the flow of blood, as 
stated by some authorities, but generally to the manner in which the 
flow is produced and the character of the blood. The epithelium, 



272 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

instead of melting off, comes away in blocks and shreds. Casts of 
whole follicles may form. The blood is produced in too sudden a. 
manner at first, and is sparsely mixed with lymphoid cells, and 
hence coagulates, instead of remaining fluid. The pain is produced 
because the endometrium is altered in essential particulars and 
because of the blood-clots. In those cases where the blood clots least 
the dysmenorrhea is least. It is to the altered condition of 
endometrium that the dysmenorrhea is due. The vaginismus and 
dyspareunia are purely secondary and dependent upon the nerve- 
irritation produced by the dysmenorrhea. 

The subject of sterility of uterine origin can be dismissed in a 
few words. 

Women with these flexed uteri who marry early in life, before 
the endometrium has undergone the structural changes described 
under the head of " Simple Endometritis " — conceive as readily as 
other women, although they may suffer from the most severe dys- 
menorrhea from clotting of the blood. It is as illogical to assume 
that a canal which admits a Simpson sound will refuse entrance to 
a spermatozoon, as that a spermatozoon may penetrate the minute 
Fallopian opening and yet not be able to enter the cervical canal 
in such cases as these under discussion. The obstruction theory 
of Sims and his followers will not meet the objections raised by 
more recent physiological and pathological investigations. The 
whole fabric of the uterus is made for the proper management 
of the decidua- forming endometrium. If this be markedly and 
generally diseased, its chief function is gone. The requirements 
on the part of the woman to conception are — patent tubes, discharge 
of an ovule, melting off of the epithelium from the surface of the 
endometrium, and engorgement of the rectiform tissue by lymphoid 
elements. If these requirements are not satisfied, conception does 
not occur. Flexure possibly produces degenerative changes in the 
endometrium, but it is those changes, and not the flexure, which 
prevents conception. Most frequently, however, the changes are 
brought about by induced inflammations. 

Therefore, with a wrong interpretation of the menstrual func- 
tion, and seeing but the grosser lesions, gynecologists have been 
but partial in their treatment of these lesions and the attending 
sterility. 

Treatment. — The indications seem to be to relieve that lesion 
which produces the changes in the endometrium and give the woman 



DISTORTIONS AND MALPOSITIONS. 273 

a new cytogenetic membrane. In the first form of anteflexion the 
uterus is dilated thoroughly and washed out with boracic-acid solu- 
tion. Now comes the essential part of the operation, for which the 
dilatation is merely preparatory. As thoroughly as possible the 
whole inside of the uterus is curetted, removing every possible ves- 
tige of the endometrium. The cavity is again washed out. Iodo- 
form gauze is then tightly packed into the uterus and the vagina 
lightly filled with the same, this being left in four days. It is then 
removed and no further treatment given. 

The operation is best done two weeks before a period. The 
patient is allowed out of bed on the third day ; she should remain 
in the house two or three weeks. If the operation is done for ster- 
ility, and if there be no suspicion of gonococci in the husband's 
urethra, connection should take place two days before and imme- 
diately after the menstruation. No pessary is used or needed. 

Anteflexion with retroversion is treated on the same principle — 
removal of the endometrium and relief of that condition which 
originally produced it. Here the latter is more difficult than in 
simple anteflexion. The uterus is steadied by the bullet forceps, 
and not drawn down much ; the canal is dilated cautiously, to half 
an inch ; after this the uterus is washed out, thoroughly curetted, 
again irrigated, and packed tightly with iodoform gauze, and the 
usual vaginal dressing applied. The packing is removed on the 
fourth day, and a light drain of gauze introduced just through the 
internal os; no pain is produced. This second dressing remains in 
two days more, and another is applied. The drains should be intro- 
duced for two weeks. The curettage is the important feature. Pes- 
saries are out of place in the treatment. If, as is usually the case, the 
cervix be hypertrophied, it is at times impossible to sufficiently dilate 
so that an effective curettage can be done and the uterus properly 
packed. Besides, something must be done to do away with the 
enlarged cervix. This can be accomplished by the following 
method : 

Anteeo-posteeioe Section of the Ceevix. 

The cervix is pulled down into the axis of the vagina, and the 
length and shape of the canal determined by the sound. A blunt, 
straight bistoury is introduced to the internal os, and the posterior 
lip of the cervix is split for two-thirds of its length, the incision being 
in the middle line. The bistoury is now introduced again and the 



274 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



anterior border of the internal os is nicked. The cervix is now care- 
fully but thoroughly dilated and the uterine cavity curetted and 
irrigated with salt solution. The parts being wiped dry, the ope- 
rator picks up the cervical mucous membrane at the old external os 
with his needle, brings out the needle upon the raw surface, and 
picks up the mucous membrane of the vaginal face of the cervix. 

Fig. 152. Fig. 153. 





The congenital]}' enlarged cervix. 



The shaded portions show the extent of the incisions. 



Tying the suture, it will be seen that the covering of the cervix 
is folded over the raw surface and is united to the cervical mem- 
brane. Using the suture as a continuous suture, the operator pro- 
ceeds down one side of the incision and closes in the raw surface 





The method of applying the running suture. 



The completed operation. 



entirely. When he gets to the angle or posterior part of the cut, 
he proceeds up the other side in a manner similar to that employed 
on the first, and upon arriving at the top the suture is tied. The 
cervical canal is now converted from the round tube which it first 
was to one of conical shape. The uterus is again irrigated and is 
packed with iodoform gauze. The vagina is also packed with gauze. 
All dressings are removed in two days and the vagina alone is 
packed. The patient is allowed out of bed in four days. The suture 
of silk is removed in about a week. After-treatment is unnecessary. 



DISTORTIONS AND MALPOSITIONS. 275 

The cervix shrinks after this operation, so that after the lapse of a 
few months but little of the hypertrophied portion is left. 

The uterus, relieved of the weight of the enlarged cervix, also 
rises in the pelvis and assumes a more forward position. Should 
the cervix be much elongated or hypertrophied, it should be ampu- 
tated. Both the amputation and the curettage may be carried 
out at the same sitting. 

If it be decided to amputate the hypertrophied cervix, not more 
should be removed than two-thirds of that which it is desired shall 
be the ultimate decrease in size. Atrophy incident to the operation 
will remove the rest. 

There are still those in America who teach and practise the use 
of stem pessaries. Inasmuch as for years we were so placed that 
we could observe daily the results of their use, we feel qualified to 
speak on the subject. Those who use them consider the cervical 
stenosis as the objective point. Having made incisions of the cer- 
vix, the uterus is not washed out and is not curetted, but dilatation 
is done. The pessary is then introduced and retained in place by 
a cotton tampon in the vagina. It is removed in three days, and 
an application of iodine or carbolic acid made to the endometrium, 
and the stem again put back. If the uterus simply be anteflexed, the 
stem will stay in without support ; but if the cervix looks out in the 
axis of the vagina, the stem must be retained in place. These 
stems are straight and are forced into place in the flexed canal. 
They act, according to those who employ them, by straightening the 
canal and establishing drainage. They keep the incised and dilated 
canals open without doubt, and, as they are left in during the menses, 
connection, and douching, the discharges are very profuse — more 
profuse, in fact, than before they were used ; hence their advocates 
consider that they are draining away discharges, when in reality 
they are producing them. Success is obtained under their use, if at 
all, after six months' or longer treatment. 

If sterility and dysmenorrhea were due, as maintained by 
nearly all stem-pessary men, to the stenosis, they should be at 
once cured by the operation. But these gentlemen treat the endo- 
metrium for a long time to " get the secretions healthy," they con- 
sidering that spermatozoa will not live in purulent secretions, in 
spite of the fact that the emissions of every gleety man are filled 
with them. They do not know that the fault lies with the struc- 
turally changed endometrium. Their applications do some good, 



276 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

but it is tardy and comes when the patient is about worn out with 
treatment. The percentage cannot be estimated accurately, but we 
have known so many inflamed tubes come from this treatment that 
we believe they do nearly as much harm as good. If used in a case 
of simple endometritis, that speedily becomes purulent. 

The stem pessary requires months to accomplish a result ; it pro- 
duces pus, it frequently causes inflammation in the tubes and peri- 
toneum ; it does not drain, and it does not cure endometritis. The 
sole beneficial feature in this method lies in the application of iodine 
and carbolic acid. Contrast this procedure with that of curettage. 
We have seen conception follow within five weeks after a curettage, 
and it not infrequently results at the second or third period follow- 
ing the operation. There is produced no pus, there is no long treat- 
ment, there are uo accidents, and the results are not infrequently 
immediate relief from the dysmenorrhea. 

It but remains for us to say that the treatment of anteflexion by 
the stem pessary is not based upon accurate ideas of the lesion and 
the function of the endometrium, and is at times altogether irrational. 

We repeat, the object of the whole operation is to give these 
women new endometria, forming under propitious circumstances, 
and as soon as possible to obtain conception in the married. In the 
unmarried the relief from the dysmenorrhea is often permanent. 

There is another procedure which, while it has little effect upon 
the condition of the endometrium, affords temporary relief from 
dysmenorrhea. We refer to dilatation without curettage. The use 
of the dilator without ether is exceedingly painful in these sensitive 
women ; it is of but temporary benefit, and must be repeated many 
times ; it is done under conditions where exact asepsis is impossible, 
and therefore has attached to it the risk of infection ; and, further- 
more, it occupies a middle position between operation and treatment, 
with none of the good results of the former, and all the dangers of 
the latter, in most hands. Long after-treatment of these nervous 
women is inadvisable, because it keeps constantly before them 
their malady. They become hypochondriacal and utterly miser- 
able, and prone to magnify their really trivial troubles. 

There are many cases where it is difficult to decide what opera- 
tion to do. The three factors which guide us in the selection are the 
symptoms calling for treatment, the amount of cervical hypertrophy, 
and the axis of the cervical canal to that of the vagina, this being 
normally from about 50° to 00°. 



DISTORTIONS AND MALPOSITIONS. 277 

In all intra-uterine manipulations the most precise asepsis must 
be observed, lest we convert a simple into a septic endometritis 
and extend a septic endometritis into a tubal or peritonitic involve- 
ment. A woman who has once had either complication occupies a 
position in society far different from one who has not, and goes 
through her lite with the possibility of celiotomy ever before 
her. 

With this caution we may say that dilatation may be done so as 
to do the patient no possible harm if the proper precautions are 
taken. Still, it is an undoubted fact that the instrument has been 
most recklessly used. If curettage is not adopted, diatation once 
every month, a few days before mensuration, will give most patients 
much relief from pain. But our experience is that the method is 
applicable to cases of short cervix only. Certain of these cases of 
dysmenorrhea suffer so much that the use of narcotics is demanded. 
If the woman be plethoric, she should be put upon an almost exclu- 
sive vegetable diet for two weeks before her perioid. To relieve the 
spasmodic pain, the following is most useful in a single dose when 
the pain begins: 

1^- Chloral hydrat., gr. x ; 

Tr. cannabis indica, TTlxv ; 

Ext. gelsemii fld., Itliij ; 

Aquae, ad fSss. 

This dose should not be repeated within six hours, and the patient 
should be put to bed with the first dose. 

If the flow is excessive after giving the first dose, Tr. cannabis 
indica in 10-minim doses may be given alone every three hours 
for six doses, or codeia gr. ^ and phenacetin gr. v may be admin- 
istered in capsule. 

The use of morphia is absolutely contraindicated, for witli 
periodic suffering it is most easy to contract the morphine habit. 
To prevent the recurrence of the attacks at each period saline 
laxatives associated with a limited diet will do much. 

Anteflexion Complicated by the Menopause. 

When the menopause occurs in old maids with anteflexion, it pro- 
duces a very distressing train of nervous phenomena which prop- 
erly come to the attention of the gynecic surgeon. The fundus 
rapidly atrophies and leaves the cervix proportionally much en- 



278 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

larged. The cervix also finally retrogrades, the nerves are caught 
and compressed in the shrinking tissue, and the discharges are 
retained. The os is but pin-hole in character, and the whole 
cervical canal much decreased in dimensions. These uteri are 
originally but poorly and irregularly developed, their owners go 
through life suffering from dysmenorrhea, and when the menopause 
comes the atrophy takes place irregularly. They are complicated 
by a simple endometritis. All the treatment that is needed is 
dilatation of the cervix. The curette and gauze packing are 
seldom required for the endometrium, but it is better to introduce 
a filament of gauze into the cervix, leaving it in for a week, 
with a gauze vaginal dressing. No after-treatment is necessary. 
These cases are often subjected to the stem pessary and elec- 
trical current. Being high-strung, nervous, almost irrational 
creatures, long continued local treatment has a deleterious effect 
upon both their mental and moral qualities. Medicinal treatment 
can give them little or no relief. If surgical aid be refused it. 
may become necessary to resort to opium in some form at each re- 
curring monthly period. Such treatment, although effective, is 
exceedingly dangerous, and should only be practised when all 
else fails. Such methods of relief as are given in the chapter on 
Dysmenorrhea should be tried before resorting to the use of this 
drug. 

Lateral Flexions. 

These are generally the result of some inflammatory lesion out- 
side the uterus, such as adhesions, and of that common form of con- 
traction in one broad ligament which follows puerperal septic sal- 
pingitis. They are not amenable to extra-peritoneal treatment, and 
are purely secondary. 

Retroflexion and Retroversion. 

Congenital retroflexion is exceedingly rare. The uterus is invari- 
ably back in the pelvis and sharply bent upon itself, the flexure 
being at the os internum. The cervix is normal or slightly below 
normal in size. The flexure is exceedingly sharp, the fundus occu- 
pying the cul-de-sac. In rare cases no sulcus can be felt between 
the cervix and the body. If at any time there has been peritonitis, 
the body of the uterus is usually adherent to the rectum, rendering 
the deformity irreducible. The anterior wall opposite the internal os. 



DISTORTIONS AND 3IALP0SITI0NS. 279 

is so thinned as to be membranous, while the posterior is much 
thickened. Schultze attempts to explain uterine flexures by ascrib- 
ing them to intra-abdominal pressure acting upon the uterus at 
some point fixed by inflammatory tissue, and he describes a retro- 
flexion due to fixation of the cervix anteriorly. The dilating and 
contracting bladder renders such a condition all but impossible. It 
is surely so where the flexure is congenital. So rare is this condi- 
tion that Winckel describes but four cases. The uterus is close 
to the sacral curve and not lower than normal. It seems to be 
displaced directly backward. The fundus presses upon the rectum, 
and the total length of the uterine canal is decreased. All have 
some form of endometritis, often purulent. The ovaries and tubes 
are usually normal in position, and do not follow the fundus. 
The symptoms are uniform, with trifling variations : continuous, 
severe backache ; pelvic tenesmus ; difficult defecation and the 
passage of small stools ; frequent headaches (occipital) , especially 




Extreme Retroflexion. 

at the periods ; dysmenorrhea, severe and identical with that 
accompanying anteflexion, with a scanty flow and passage of clots. 
Bimanual examination reveals the direction of the canal. The 
bladder is attached to the uterus below the level of the internal os. 
Rectal examination, combined with abdominal palpation, detects 
the degree of flexure and the intimate approximation of the cervix 
and fundus. 

Treatment. — The indications are for the removal of the endo- 
metritis and the establishment of thorough drainage. Replacement 
is impossible by the use of the sound or by manipulations, even 
under ether. 

The Operation. — The posterior lip is incised through from above 



280 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

the internal os ; the uterus is dilated, curetted, and irrigated. The 
hemorrhage is free, inasmuch as the circular vessels are cut. To 
check this, a tight iodoform gauze tamponade is indicated, to be 
retained in place by vaginal gauze tampons for at least two days. 
It is then removed and vaginal gauze packing substituted. The 
treatment lasts for three weeks. With the short vaginas and struc- 
turally altered uteri we cannot see how Alexander's operation or 
ventro-fixation could possibly be of benefit, and pessaries are worse 
than useless. 

Acquired Retroflexion and Retroversion. 

Etiology. — Retroflexions and retroversions accompanied by 
tumors will not be described. Their proper treatment is removal 
of the neoplasms, after which, if they still persist, they are to be 
dealt with as are other retrodisplacements. 

Retroposition of the uterus may ensue as a result of conditions 
in its own tissues and from lesions in the supporting structures. 
Any factor tending to enlargement of the uterus, which at the same 
time softens its walls, may cause retroposition. Such are pregnancy, 
septic endometritis, and subinvolution. There is so much discrep- 
ancy in the relative frequency of retroflexion and retroversion given 
by different authors that it is impossible to furnish an accurate 
ratio. Retropositions are frequently found after the adnexa of 
both sides have been removed without adopting some means to 
retain the uterus in its proper position. 

The cervix being more or less a fixed point, the heavy and 
softened body falls backward. A very common cause is too long 
confinement in the dorsal position in bed after labor, especially as 
the uterus is apt to be, under this circumstance, in a pathological 
state. 

A sudden fall from a height, producing rupture of the round, 
broad, or utero-sacral ligaments, a sudden increase of the intra- 
abdominal pressure, as the body being crushed under a weight, may 
produce retropositions of the uterus by interference with its supports ; 
or, they may be produced by a lesser and more gradual increase in 
the intra-abdominal pressure, operating for some time upon a soft- 
ened uterus. But the common association of causes is a break in 
l he pelvic floor, together with uterine enlargement. 

The chief single cause is rupture of the perineum. The walls 
of the collapsed bladder completely fill the space between the 



DISTORTIONS AND MALPOSITIONS. 281 

uterus and pubes ; therefore displacement forward is possible to 
but a very slight degree. The perineum being torn, the sphincter 
ani does not feel the full opposing force of the levator ani in defeca- 
tion, so more or less straining at stool becomes necessary. The result 
is that the feces, meeting the closed sphincter, seek a relief from the 
intra-abdominal pressure in the direction of the posterior vaginal 
wall, causing it to bulge forward. This drags on the posterior lip 
of the cervix, the uterine axis approaches that of the vagina, and 
the whole organ descends a little. If the uterus be enlarged as 
from a recent pregnancy, it will, yielding to the pressure from 
above, either fall backward or its fundus will bend upon the cervix, 
causing a flexion. 

Fig. 157. 




Ventro-recto-vaginal Reduction in Uterine Retro-displacement. 

Retroverted and retroflexecl uteri are low in the pelvis, as the 
anteflexed uteri are high up. 

The element of intra-abdominal pressure is operating continu- 
ously, and may, apart from defecation, cause the displacements men- 
tioned, where the supports are broken, more especially when there 
is a lack of tone in the uterine muscle. 

Septic conditions, especially those acutely established in an abort- 
ing uterus, frequently result in acute retroflexions, which disappear 
in a few days if the sepsis is removed, and the uterine muscle regains 
its tone. Pelvic peritonitis and inflammatory processes in the tubes 
and ovaries also cause retropositions by the formation of false bands. 
Retroflexion and retroversion are usually accompanied by endo- 
metritis. Certain irregular changes take place in the muscularis, 
such as thinning of the anterior and thickening of the posterior wall. 
The broad ligaments are twisted and the venous circulation retarded, 



282 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY 



leading to a varicose condition of the pampiniform plexus. This in 
time predisposes to prolapse of the ovaries and tubes. Retroposition 
is the first step to prolapsus. 

Symptoms. — Women with retroversion or retroflexion complain 
more of backache and a dragging sensation in the pelvis than of 
any other symptoms. These may be so great as to amount to act- 
ual inability to walk. Leucorrhea is a prominent symptom, the endo- 
metrial discharge being milky or purulent. As a result, erosions of 
the cervix may occur. In septic or inflamed uteri every movement 



Fig. 158. 




Bimanual Reposition of the Retroflexed Uterus: first step. 



is felt in the tender organ. Defecation is difficult and often painful,, 
hence postponed as long as possible. Costiveness results, with the 
common accompanying train of anorexia, foul breath, etc. Dragging 
upon the bladder sometimes causes the sphincter vesicas to leak, and 
dribbling of urine occurs upon laughing or exertion. Pains down 
the front of the thighs are frequent, and are increased on motion. 
Occipital headache and burning pain in the nucha, inability to con- 
centrate the thoughts, melancholia, hysteria, and peevishness are 
common reflex nervous phenomena. The endometrium commonly 
becomes hypertrophic, and gives rise to increased menstrual flow. 



DISTORTIONS AND 2IALP0SITI0NS. 



283 



This, however, is not painful as a rule, owing to the fluid condi- 
tion of the blood and patency of the canal. 

Diagnosis. — Upon examining these cases of posterior displace- 
ment, the uterus is found low in the pelvis. If there be pronounced 
retroversion, the linger first touches the posterior lip of the cervix, 
and the uterine tissue continues from this point backward and down- 
ward. There is absence of the body from its normal position, and rectal 
touch demonstrates its presence in the cul-de-sac in retroflexion ; in 
retroversion the body presses on the rectum higher up. In aggravated 

Fig. 159. 




Bimanual Reposition of the Retroflexed Uterus : second step. 

cases the ovaries also lie so low as to be felt easily to either side of 
the uterus. The fundus is tender, and more or less enlarged accord- 
ing as the displacement occurs post-partum or not. 

The local tenderness and size, with many of the subjective symp- 
toms, vary greatly according to the causative factors. 

Retropositions of the post-partum uterus, or the organ materially 
softened by endometritis and metritis, have commonly both versions 
and flexions associated. Therefore one author will describe a cer- 
tain case as retroflexion, while another places it as retroversion. If 



284 



AN A3IERICAN TEXT- BO OK OF GYNECOLOGY. 



the uterus be flexed to any extent, there will be a convexity on the 
anterior surface of the organ where normally there should be a con- 
cavity, and the reverse on the posterior border. The finger in the 
rectum, with abdominal palpation, makes the diagnosis absolute, for 
every portion of the organ can thus be reached. In all cases, when 
necessary, the sound will demonstrate the direction of the uterine 
canal. It is a matter of importance to determine whether or not 
the uterus can be replaced or whether it is adherent to the rectum. 
Before doing this one should know that there is no suppurative 
focus in the tubes or ovaries. 




Bimanual Reposition of the Retroflexed Uterus ; elevation of the fundus by the internal hand. 

Treatment. — Two objects are aimed at — the return of the dis- 
placed uterus to its natural position and the cure of any coexisting 
disease of this organ or its adnexa. One of four methods of replace- 
ment may be adopted : replacement by the hands alone, by the knee- 
chest position, by the sound, or by the repositor. 

In thin women only can the uterus be replaced with ease by the 
unaided hands. In fat women it is often rather difficult, and is 
then best accomplished by means of the finger in the rectum, or by 
the knee-chest position. These two methods have great advantage 
over all others in that they are applicable to cases with septic endo- 



DISTORTIONS AND MALPOSITIONS. 



285 



metritis, for they do not necessitate invasion of the inside of the 
uterus. They should be tried faithfully and persistently before 
resorting to other means. These two methods of replacement are 
the only ones which give good results. Rare indeed must be the 
cases in which they fail when properly tried. 

Bimanual Reposition. — The patient assumes the half-reclining 
posture, with the knees flexed on the abdomen and the clothes per- 
fectly loose. The finger is introduced into the vagina and passed 
behind the cervix. The tip is gently bent and attempts are made 

Fig. 161. 




Bimanual Reposition of the Retroflexed Uterus; the external hand taking charge of the fundus. 

to pull the cervix forward toward the symphysis pubis so as to 
dislodge the fundus from the hollow of the sacrum. The free 
hand on the abdomen is crowded down hard, following the curve of 
the sacrum. The object is to keep as far back in the pelvis with 
this hand as possible, and to pin the retroposed uterus against the 
symphysis. No attempt has so far been made at reduction — merely 
the preliminary step of fixing the organ. The vaginal ringer is now 
carried behind the body, which is lifted as high as possible along 
the curve of the hand pushed into the abdomen, until it is well 



286 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



in front of the fingers of the free hand. This is then moved 
slowly forward toward the pubis until resistance is met with. 
This maneuvre bends the body of the uterus upon the cervix. 




Bimanual Reposition of the Retroflexed Uterus, completed. 

The vaginal finger is then placed in front of the anterior lip of 
the cervix, and this is pushed upward and backward to the pro- 
montory of the sacrum, while at the same time the body is held 
anteriorly. The last movement is to push the cervix suddenly 
upward in a straight line toward the pelvic brim by the finger 
beneath the os tincse. The uterus is now in an anteverted position. 
If the cervix is held high in this position while the patient gets up 
and stands, the intestines will fall behind the uterus and the intra- 
abdominal pressure keep it in place, or if it is intended to fit a sup- 
porting pessary, this should now be done while the cervix is held 
upward and backward. 



DISTORTIONS AND MALPOSITIONS. 287 

Knee-chest Reposition. — The patient is placed in the knee-chest 
position and the perineum is lifted up with a Sims speculum. This 

Fig. 163. 




at once allows the intestines to fall away from the pelvis into the 
abdominal cavity. The cervix, thus exposed, is caught up with 
a tenaculum and drawn well forward toward the vulvar orifice. By 
this movement the fundus is drawn forward sufficiently for it to 
swing past the promontory of the sacrum, by the aid of gravity, 

Fig. 164. 




Replacement of Retrodisplaeed Uterus by means of the Uterine Repositor, with the patient in the knee- 
chest position. 

which it will do in a small proportion of cases. Should it not do 
so, as the cervix is drawn forward, the fundus is lightly pressed 
upon by means of the repositor shown in the cut, and thus forced 
into place. A firm cotton tampon is then placed anterior to the 
cervix, and the patient allowed to assume a recumbent position ; as 
she does so the intestines fall back into their normal position, and 
with the intra-abdominal pressure aid very materially in keeping 
the uterus forward. 



288 AN AMERICAN TEXT-BOOK OE GYNECOLOGY. 

The uterus may be replaced in women who are stout, and in 
others who are unable to relax the abdominal muscles, by putting 
them in the knee-chest or dorsal position, and employing combined 
rectal and abdominal reposition. The manipulation is very similar 
to that of the bimanual method just described. 

Replacement with the sound is accomplished by curviug the instru- 
ment so that it may be introduced, and then causing the instru- 
ment to make a half sweep. The whole weight of the organ falls- 
on the point of the sound, which lacerates the endometrium, and 
has in innumerable cases perforated the uterus. In this maneuvre 
the organ is not raised as a whole, but the fundus is merely forced 
into a different relationship to the cervix. If there be any adhesion 
or other restraint to the raising of the organ, the risk of perforation 
becomes very great, for there is no escape from whatever force may 
be used. 

The better method in all cases where manipulations fail — and 
only when they do fail after repeated trials — is as follows : The pa- 
tient being on the back or in Sims' position the bladder and bowels 
empty, the repositor is introduced very gently into the vagina and 
locked ; the point is made to enter the cervix and engage there, 
when the instrument is unlocked. This makes a sound with a joint. 
The stem portion should be only long enough to reach the internal 
os. Then by gentle and careful manipulation the intra-uterine por- 
tion is coaxed to enter the canal until it has just passed the internal 
os. The proper length has been selected previously and fitted to the 
hinge. The finger of one hand is then pushed high up against the 
back of the fundus, and attempts to lift it are made by turning the 
screw in the handle of the instrument. If there be no adhesions, the 
uterus will become anteverted, and, more, it will be made, cervix and 
body, to assume the normal position in the pelvis ; and this is an im- 
portant property not attaching to the use of the sound. The instru- 



r% 



tnent is removed, still unlocked, by supporting the cervix with one 
finger against it and using the symphysis as a fulcrum to slip the 
staff out of the uterus. If there be intimate adhesions between the 




DISTORTIONS AND MALPOSITIONS. 



289 



fundus and rectum, the efforts to replace the organ will merely drag 
up the bowel for a short distance, and with the finger in the rec- 
tum, the anterior rectal wall will be felt to leave the finger while 
such effort is being made. Or, should the adhesions be of some 
length, the organ will be replaced to a certain extent only, and 
then checked by the false bands. We are perfectly aware that 
there is risk attached to this maneuvre, but with our present 
method of cleansing the operator, vagina, and instrument this is 
reduced to a minimum. We do not consider that any more danger 
attaches to its use than to that of the sound. 

If it be desired to support the uterus by tampons after replacing 
it and removing the repositor, the patient should be in Sims' pos- 
ture. It will then be much easier to replace the organ, as the intro- 
duction of the speculum allows the intestines to gravitate away 
from the uterus. A glance at Waldeyer's plate demonstrates the 
manner in which this reposition takes place. Were the uterus 
retroverted and the bladder entirely empty, elevating it in the axis, 




Intestines 



.. Urethra 
Vagina andHtftne 



Girl Aged Thirteen, Frozen Section, showing direction of intra-abdominal pressure ; relations of uterus 
before puberty ; and great strength of pubic segment of pelvic floor. 



of the vagina to a point near the sacral promontory would inevitably 
result in the fundus being dragged forward by the bladder and 
associated tissues. 

19 



290 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



This could all be accomplished with the finger against the cer- 
vix were the finger long enough. The stem is merely for the pur- 
pose of affording a hold on the cervix. By observing even the 
ordinary rules governing all intra-uterine manipulations there is 
not much danger attending the use of this instrument. It elevates 
and replaces the uterus merely by following back the path in which 
the displacement came. It takes advantage of the anatomy, and 
does not act against it. The weight of the organ is borne on the 
whole length of the stem in the cervix, and not on one point, as in 

Fig. 167. 




Waldeyer's Frozen Section of the Female Pelvis; u, uterus; J?, bladder. 

the use of the sound. With it the exact degree of mobility may be 
appreciated. But it is not to be used where there are pathological 
conditions in the adnexa, or septic endometritis, and therefore must 
have a very limited application. Its use as a means of diagnosis of 
pelvic neoplasms cannot too strongly be condemned. It should be 
employed only in those cases of free retroposition where there is 
no septic focus in the uterus, peritoneum, tubes, or ovaries. This 
cannot too strongly be insisted upon. 

Again, we repeat, this method is to be used only when manipu- 
lation fails or is impossible, but is always to be preferred to the 



DISTORTIONS AND MALPOSITIONS. 



291 



reposition by the sound. Both are to be considered only as last 
resorts. 

As a matter of fact, no attempt should ever be made to forcibly 
replace or otherwise interfere with a uterus which is bound in its dis- 
placed position by adhesions. It is impossible to determine accu- 
rately whether or not there is disease in the uterine appendages in 
many cases, and irretrievable damage may unwittingly be done in 
the manipulations. The only safe and intelligent operations for 
these conditions are intra-abdominal. 

Comparatively few retro-displacements exist without some com- 
plicating inflammatory trouble, either intra-uterine or intra-abdom- 




Diagnosis and Reduction of Retroflexion by the Sound. 



inal, and the symptoms usually arise from the complications and not 
from the displacement. It is all the more necessary, therefore, to 
be on one's guard in selecting proper cases for this treatment. 

A uterus may be caught between rigid utero-sacral ligaments, and 
be so tender as to convey the impression that it is adherent. The 
question of mobility or fixity in a doubtful case can always be def- 
initely settled under narcosis. No apparently fixed uterus should 
be treated as such until attempts at replacement have been made 
while the woman is unconscious. 

The object of all treatment must be to have the uterus approach 



292 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

the normal in size and character of its walls, and to place the sup- 
porting agents in a healthy condition. Therefore, if the uterus be 
retroposed and enlarged, it is essential that it be supported in the 
proper position while such means are employed as will reduce its 
size. After the uterus has been replaced in such cases it is kept in 
position by placing in the cul-de-sac a cotton tampon soaked in some 
depleting agent, as boro-glyceride or ichthyol-glycerin, and then 
introducing a tampon of lamb's wool. This latter should be put in 
lengthwise, rolled hard, and turned sideways, so that the ends will 
rest against the inferior pubic rami and the tampon be in front of 
the cervix. When the patient stands the downward motion of the 
cervix is retarded, and intra-abdominal pressure forces the corpus 
on the bladder. Combined with this, intra-uterine injections of tinc- 
ture of iodine are to be used in cases not infected and where the 
uterus is enlarged. The uterus being elevated, its circulation is 
improved ; being in proper position, drainage is secured ; and the 
astringent intra-uterine and depleting hot-water vaginal injections 
tend to a reduction in size. It is well to remember that a large 
percentage of cases of retroposition give rise to no symptoms 
whatever, and are discovered only upon the supervention of some 
complication. 

When endometritis or pelvic inflammation complicates the 
displacement, it is to be treated as set forth in its respective 
chapter. All such complications must be most carefully attended 
to if successful results are expected. Of those cases of retro- 
displacement giving rise to serious symptoms the larger proportion 
are caused by these complications, and not by the displacement 
per se. 

Having placed the organ in the proper position and condition, if 
there be tears in the pelvic floor they must be repaired. Nothing 
tends to the production of the displacement more than costiveness 
and straining at stool while the woman is still puerperal. There- 
fore in all cases where the perineum is torn it is better to give a soft- 
ening enema each day, rather than allow her to strain at stool and 
occasion a rectocele. Certain cases of retroposition are symptomati- 
cally relieved upon the establishment of thorough drainage, and 
commonly the attendant endometritis is cured. 

Artificial supports, as pessaries, are contraindicated until the 
uterus returns to a healthy condition and all lacerations condu- 
cing to displacement are repaired. When that is done, we will find 



DISTORTIONS AND MALPOSITIONS. 293 

in roost cases that pessaries are not needed. The tampon acts so 
much better in the majority of cases where any such support is 
called for that the pessary is falling more and more into disuse. 
The tampon has none of the dangers attendant upon the use of 
the pessary, and is even more effective. 

Retroversion without enlargement, such as we find in the unmar- 
ried, is exceedingly difficult to treat. Here one of three things 
must be done : either fit a pessary, or perform Alexander's opera- 
tion, or hysterorrhaphy. 

If it is decided to fit a pessary, this should be done only after 
the uterus is replaced. It is presumed that the integrity of the 
pelvic floor has been made or is perfect. Therefore the apparent 
vaginal space while patients are on the back is not the actual when 
they are standing. So it is that a pessary which seems to be loose 
while the patient lies down becomes too tight as soon as she 
assumes the upright position, because of the contraction of the 
pelvic muscles to support the organs against the intra-abdom- 
inal j)ressure. While the pessary is in situ, the finger should 
pass all around it with ease. Pessaries act, not by supporting the 
corpus, but by pushing the cervix up away from the symphysis and 
pelvic floor, thereby enabling the bladder and the weight of the 
intestines to drag forward and retain the corpus. It would be unfor- 
tunate could a pessary be applied so that it extended up into the 
cul-de-sac higher than the internal os : ulceration of the vagina 
would be inevitable. Fortunately, unless the pessary be excessively 
long, this is impossible of accomplishment. 

The soft-rubber ring, or the Smith-Hodge pessary of hard 
rubber, is preferable to all others. The Smith-Hodge pessary 
may be softened and bent into any shape by immersion in boiling 
water. 

If the pessary produces the least pain, it should be removed by 
the patient at once. And it is positively contraindicated where 
there is any disease of the adnexa, septic endometritis, urethritis, 
vaginitis, lacerated perineum, cystitis, adhesions, and whenever the 
uterus bends back over the instrument. Not often, then, can 
pessaries be employed with advantage. They are of most ser- 
vice in cases of displacement following labor or from any other 
acute cause. 

Pessaries should be introduced as follows : 

The patient is placed on the back and the uterus replaced. It 



294 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



is essential that the bladder and bowel be empty. The labia are 
separated by the fingers of the left hand. The index finger of the 



Fig. 1G9. 




Introduction of Pessary, first stage. 



right hand holds the well-greased pessary, the thumb and middle 
finger steadying it. The broad end of the pessary is introduced 




Introduction of Pessary, second stage. 



with one side under the pubes and obliquely, so as not to press upon 
the urethra. As the advancing bar of the pessary passes the vulva 



DISTORTIONS AND MALPOSITIONS. 



295 



the hand holding it is carried high in front of the pubes, so that the 
pessary may be inserted in the curve of the pelvic outlet. As the 

Fig. 171. 




Introduction of Pessary, third stage. 



pessary advances it is rotated until it lies on its flat side on the floor 
of the vagina. When it has entered the vagina so as to reach the 



Fig. 172. 




Introduction of Pessary, fourth stage. 



cervix, the index finger of the right hand is passed into the vagina 
under the anterior bar of the pessary, until it reaches the posterior 



296 AN AMERICAN TEXT- BO OK OF GYNECOLOGY. 

end, over which it is hooked, pressing the bar downward and back- 
ward, thus guiding it into place behind the cervix. The point of 
the pessary should not press upon the neck of the bladder or the 
urethra, but it should be curved downward, so as to take support 
from the converging pubic rami, thus leaving a space between the 
arms of the point for the urethra. Again, the base should not be 
so curved as to press against the ischial rami below. A fairly good 
test is to pass the finger all around the pessary while the woman is 
on her back. If that may be done, when she stands and the 
muscles of the floor of the pelvis contract, the pessary will be snug 
enough. 

Pessaries should not cause the least pain, and patients should not 
know that they are wearing them except by the relief of disagreeable 
symptoms. Those pessaries having rings into which the cervix fits 
are objectionable, in that the cervix settles down into the ring so 
snugly as to obstruct the egress to its secretions. 

Stem pessaries with a bow attachment are dangerous affairs, even 
more so than stems alone. 

Pessaries which fasten to belts outside the body are not to be 
used, except in cases of complete prolapse where the patient refuses 
all surgical treatment. Under these circumstances they are often 
of great value. 

Fig. 173. 




for Complete Prolapse. 



Even in cases temporarily benefited by the use of pessaries the 
questions must arise : How long can the patient wear one ? Do 
they ever cure, and are they not merely unsatisfactory makeshifts ? 
In cases in which they appear of use, are there not better methods ? 
It is far better for the patient to go twice a week to the phy- 
sician for the introduction of a supporting tampon of sterilized 



DISTORTIONS AND MALPOSITIONS. 297 

wool if it can be retained than to wear a pessary, even under 
observation. 

Granted that the uterus has been gotten into a normal condition 
and all lacerations of the pelvic floor are properly repaired, it is 
occasionally necessary to use pessaries. 

Patients who use pessaries should take daily cleansing douches, 
and have the supporter removed once a month, cleansed, and allowed 
to remain out for twenty-four hours before being replaced. 

Surgical treatment of retro-displacements has for its object the 
replacement of the womb in its proper position and the cure of 
the complicating disorders. It is divided into two classes : those 
operations performed through the vagina, and those through an 
abdominal incision. 

Experience has taught that with one possible exception — posterior 
vaginal section as proposed by Pryor — the results of all the vaginal 
operations for the purpose of replacing the uterus which necessitate an 
incision of the vaginal vault, either anterior or posterior, are fraught 
with so much future danger to a woman in the child bearing period 
that they need only be mentioned to be condemned. 

Posterior Vaginal Section. — The patient is placed in the lith- 
otomy posture. The uterus is curetted and irrigated, but not packed. 
Pulling the cervix down, the operator cannot readily determine the 
point of reflection of the vagina from the cervix ; but upon pushing 
up the cervix he will see a prominent crescentic fold form just 
behind the cervix. This is incised with blunt scissors for a distance 
of about one inch. The cut extends through the vaginal mucous 
membrane only, and at the sides stops short of the middle line. 
But one layer now remains to be severed- — viz. the peritoneum. 
The anatomical fact must be borne in mind that sometimes the peri- 
toneum is reflected from the rectum to the uterus at a point opposite 
the internal os, and in other cases it dips deep down behind the pos- 
terior vaginal wall. Therefore it is safer to not at once cut through 
the tissues lying beneath the vaginal incision, but to insert one 
finger and shove it up to the level of the internal os, while down- 
traction upon the uterus is maintained. If the finger has not pene- 
trated to the pelvic cavity by this maneuvre, the pocket formed by 
the finger is wiped dry and the cavity inspected. The peritoneum 
will be seen bulging out into the incision at each movement of the 
diaphragm. Where the peritoneum is attached to the uterus it is 
seized with mouse-toothed forceps and carefully divided with scis- 



298 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



Fig 174. 



sors. Inserting one finger into the opening, the operator makes a 
thorough digital examination of the pelvic contents. Slight adhe- 
sions are readily broken up. If dense or extensive adhesions exist, 
the case is more properly one for hysterorrhaphy. If satisfied that 
all adhesions have been severed and that the adnexa are free from 
disease, the operator wipes the pelvic cavity dry. The nurse has 
prepared a roll of iodoform gauze to which is attached a stout silk 
cord, and this the operator places just within the cut edges of the 
peritoneum. This roll of gauze should fit the incision snugly, and 
should not be so long as to project up above the level of the internal 
os, or project so far into the vagina as to be shoved up into the pel- 
vis by the patient's movements. The uterus is now packed with 
iodoform ganze. Having properly placed this roll of gauze, the 
cervix, with the gauze still in place, is shoved upward and backward 
in the axis of the vagina until the vaginal walls are straightened 
out and the corpus uteri is manipulated into anteversion. While 
holding the cervix high up by means of the long retractor the ope- 
rator places wads of gauze in front of and to each side of the cervix, 
so as to maintain the cervix in a backward 
and upward position (Fig. 174). This will 
necessitate packing the vagina very snugly, 
sufficiently so as to encroach upon the 
bladdder-space in front and rectal space 
behind. A good deal of dexterity is re- 
quired to properly place the roll of gauze, to 
replace the uterus, and to maintain it in an 
anteverted position by means of the vaginal 
packing. A permanent catheter is inserted 
into the bladder and the sphincter ani dilated. 
In forty-eight hours enough vaginal packing 
is taken out to enable the operator to remove 
the uterine packing. This latter is not re- 
placed, but the vagina is again packed as 
nearly as possible as at first. The self-retain- 
ing catheter is removed after washing out the 
bladder with boric-acid solution. In seven 
to ten days the patient is placed in Sims' position and given chloro- 
form. All the vaginal gauze and the gauze roll in the cul-de-sac 
are removed. Another loose plug of gauze is inserted into the cul- 
de-sac opening and the vagina again tamponed with gauze. The 




U, uterus ; V, vagina; E, rec- 
tum; X, wad of gauze. The 
cul-de-sac has been opened, the 
uterus replaced, and the wad of 
gauze placed in the incision. 
The vagina is distended with 
gauze, which is not shown, but 
the direction of effort of the vag- 
inal gauze is indicated by the 
arrow. 



DISTORTIONS AND MALPOSITIONS. 299 

second dressing will not require narcosis, and is made six days after 
the first. Thereafter the dressings are made as soon as they appear 
wet with the broken-down lymph and serum from the peritoneal 
surfaces. Throughout the entire treatment the cervix uteri must be 
kept in its position either by a full vaginal packing of gauze or by 
placing in front of the cervix a roll of gauze placed transversely, 
its ends resting against the lateral vaginal walls. The patient is 
usually allowed out of bed after the second dressing or in about two 
weeks. Little or no pain is produced by the operation, and hence 
no morphia is indicated. The object of this operation is to produce 
a mass of adhesions between the cervix, meso-rectum and utero- 
sacral ligaments. This anchors the cervix high and back, allowing 
of the freest movement of the corpus uteri. So long as this scar- 
tissue remains the uterus will be maintained in an ante verted posi- 
tion through the intra-abdominal pressure acting upon the body of 
the uterus. And, inasmuch as the new union between the cervix 
and utero-sacral ligaments is underneath the jn^omontory of the 
sacrum, there is little tendency for it to break away ; for the 
cervix is protected against the direct influence of the abdominal 
pressure. 

In the course of time the mass of lymph which forms 
behind the cervix becomes organized into suspending bands. 
During this lymph-formation there is neither temperature nor 
infection. 

It may be said of this operation that it supposes cutting but two 
anatomical layers — vaginal mucosa and peritoneum. There are no 
vessels to ligate, and no sutures to apply. 

All cases of fixed retroposition in which there is pus-formation 
in tube, ovary, or broad ligament distinctly contraindicate this 
operation. 

Of the operations through abdominal incisions for the correction 
of retro-displaced uteri but two have, stood the test of experience — 
Alexander's operation and hysterorrhaphy. The operations devised 
by Wylie, Baer, and Dudley, having for their object the intra- 
abdominal shortening of the round ligaments, give promise of future 
usefulness. 

Wylie or Baer's Operation. — The abdomen being opened, the 
inner side of the round ligaments are scraped, so as to make their 
surfaces raw ; then, around a fold of each, three silk ligatures are 
passed, so as to include most of the ligament and fold the raw peri- 



300 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



toneal surfaces on each other. The ligaments are thus shortened, 
the folds being external. 

Fig. 175. 




"S^ 



0^^^ 



Operation proposed by Wylie and Baer for Retro-displacement of the Uterus. 

Dudley's Operation. — The round ligaments in this case are 
brought in front of the uterus and attached to its surface by silk 




Operation proposed by Dudley for Uterine Retro-displacement. 

sutures after the approximated peritoneal surfaces have been de- 
nuded. 

Alexander's operation is an exceedingly rational one, and practi- 
cally accomplishes the result most effectually where the case is 
proper for its application. It may be properly applied in those 
cases of retro-displacement which are not complicated by adhesions 
or disease of the adnexa. This being so, the operation has but a 
small field of usefulness. Should adhesions exist, they would de- 
stroy the results of the operation, and by this procedure no way of 
breaking them up exists. Nor is there any method by which the 
adnexa may be examined and appropriately treated should they 
prove to be diseased. Diagnostic skill has as yet not reached such 
a point that either of these conditions can be determined with cer- 
tainty in all cases without the abdomen being opened. Therefore, 



DISTORTIONS AND MALPOSITIONS. 301 

cases to which Alexander's operation could properly be applied must 
often be submitted to an hysterorrhaphy, on account of the uncer- 
tainty of the local conditions in the pelvis. 

It is an undisputable fact that the vast majority of retro-displaced 
uteri which give rise to annoying or serious symptoms are com- 

Fig. 177. 




the 'fundus and posterior wall to the 

plicated by inflammatory disease of either the uterus itself or its 
adnexa, or the results of such inflammations, and that the symptoms 
arise, not from the displacement, but from the complication. There- 
fore most retro-displacements must be looked upon not in the light 
of the displacement, which in the vast majority of cases would in 
itself give rise to no symptoms, but in the light of the complica- 
tions. We therefore treat the complications, not the displacement 
— otherwise we may expect little or no results. For the best accom- 
plishment of this, as far as intrapelvic complications are concerned, 
hysterorrhaphy is the only operation worth considering. In this 
procedure the abdomen is opened, and the pelvis and all its contents 
carefully examined and intelligently studied. Any lesion which 
exists is with certainty detected and properly treated. It is often 
found after this that hysterorrhaphy need not be performed. 

Alexander's Operation. — The indications for this operation — 
shortening the round ligaments — are limited. Granted that the 
perineum has been repaired and all apparent lesions of labor cor- 
rected, yet the organ persists in a retroposed state, in spite of well- 
directed efforts with replacement, pessaries, and tampons to keep it 
forward. There are no adhesions, and no tubal or ovarian disease 
or intrapelvic adhesions involving the uterus. In other words, all 
the pelvic organs seem to be in a healthy condition, but the 
uterus maintains a retroposition, which still gives rise to symp- 



302 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



toins. These, and only these, are the cases for Alexander's opera- 
tion. They must be exceedingly rare. The preparations are as for 
a celiotomy. 

Just prior to shortening the round ligaments the uterus is always 
curetted. The operator then satisfies himself by bimanual manipu- 

Fig. 178. 




spine ; B, crural hernia ; 
, external oblique muscle: E, saphena vein; ]■", falciform process of 
the saphenous opening; G, femoral artery in its sheath ; II, femoral vein in its sheath; I, sartorius 
muscle; K, internal oblique muscle; /;, conjoined tendon; LL, transvcrsalis fascia; M, epigastric 
artery; N, peritoneum; 0, anterior crural nerve; P, hernia within the crural canal; QQ, femoral 
sheath : K, (jimbeniat's ligament. 



laiion that the uterus can be thrown forward and the pelvis is free 
from disease. An incision two inches long and nearly parallel to 
Poupart's ligament is carried from the site of the internal inguinal 
ring downward and inward, terminating just within the spine of the 
pubis. Careful location of the pubic spine from the time of begin- 
ning the operation until the anterior wall of the inguinal canal is 
opened is absolutely essential to success. The subcutaneous fat is 
divided until the glistening aponeurosis of the external oblique 
muscle is exposed. The external inguinal ring is now either ex- 
posed to view or located by the touch. A grooved director is inserted 
through the external ring and passed along the inguinal canal, 
directly behind the aponeurosis of the external oblique, until its 



DISTORTIONS AND MALPOSITIONS. 



303 



point is over the site of the internal ring. Cutting upon the 
director exactly in the direction of the fibres of the external oblique 
aponeurosis, one sweep of the knife lays open the anterior wall of 
the inguinal canal along its whole length. All hemorrhage is now 
absolutely controlled. An assistant exposes the contents of the canal 
by drawing apart the lips of the incision with the aid of tenacula. 
The lower fibres of the internal oblique muscle are seen crossing 
the upper half of the canal. In a fair proportion of cases the lower 

Fig. 179. 




The Round Ligament and its Topographical Anatomy : G, glands in the neighborhood of Poupart's liga- 
ment ; H, glands in the neighborhood of t lie saphenous opening; I, sartorins muscle seen through its 
fascia; d, aponeurosis of the external oblique .muscle ; C, external portion of the round liooment. The 
other letters refer to the same parts as seen in the preceding figure. 

end of the round ligament is at once exposed to view, emerging 
from beneath the lower border of the internal oblique ; more gene- 
rally it is well covered and entirely hidden from view by this muscle 
and an investment of fatty tissue. If the ligament is not at once 
exposed to view and recognized, it is to be searched for in the follow- 
ing manner : Retract the internal oblique muscle upward and inward 
by a blunt hook. Take two small blunt hooks, one in either hand, 
and sweep one of them, point downward and outward, along the 
posterior and outer walls of the canal from the depths of the wound 
skinward, hooking the entire contents of the canal. By teasing 



304 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



these contents apart, more or less, by means of the two blunt hooks, 
the round ligament, surrounded by fat and muscular and tendinous 




Incision, 5 ctin. long, through aponeur- 
osis of external oblique, laying 
open inguinal canal from external 
to internal ring, and exposing in- 
ternal oblique muscle and round 
ligament. The ligament is more 
or less concealed according to 
greater or less development of in- 
ternal oblique: s., skin ; s.c.f., sub- 
cutaneous fat; a.e.o., aponeurosis 
of external oblique: to., internal 
oblique ; r. L, round ligament. 




Isolating round ligament from its at- 
tachments in inguinal canal: s., 
skin ;s.c.f., subcutaneous fat; i. o., 
internal oblique ; o. e. o., aponeur- 
osis of external oblique; r. /., 
round ligament. 



fibres from the internal oblique and accompanied by the ileo-in- 
guinal nerve, will soon be recognized, and can be followed to the 
internal ring. The ligament is separated from its investments in the 




drawing round ligament ou 
i. a., inici rial obliqui ; 
if external ob 



11 and stripping back, investing peritoneum of broad ligament: 
(nncous fnt; /', peritoneum; r.l., round ligament; a.e.o., apo- 



canal, care being taken not to injure the ileo-inguinal nerve. The 
ligament is now drawn out at the internal ring. As the ligament 



DISTORTIONS AND MALPOSITIONS. 



305 



gradually emerges at the internal ring the investing peritoneum 
comes with it. This is stripped back into the abdomen as the liga- 
ment emerges farther and farther, until finally a finger in the depths 
of the wound will feel the cornua of the uterus. The opposite round 
ligament is sought, and drawn out in the same way. After securing 
the desired position of the uterus by traction upon the ligaments, 
and adjusting the latter nicely along the bottom of the canal, the 
wounds are closed by sutures. The parts are brought together 
much after the principle of Bassini's operation for hernia. 




Deep tier of buried running suture of forty-day catgut, embracing internal oblique and transversahs 
muscles, round ligament, and Foumart's ligament. Deep part of uppermost loop of suture (not 
showing in cut) passes at level of and embraces margins of internal ring: s., skin ; s. c../., subcuta- 
neous fat; a. e.o., aponeurosis of external oblique ; r.L, round ligament; P. I., Poupart's ligament. 

Beginning at the upper angle and inner side of the right wound, 
the first sweep of a medium-sized curved needle armed with silk 
pierces the aponeurosis of the external oblique, the underlying 
internal oblique and transversalis muscles, the margins of the in- 
ternal ring, the round ligament as it emerges between them, and the 
projecting shelf of Poupart's ligament. The succeeding loops of 
the deep tier of sutures, three or four in number, pierce the internal 
oblique and transversalis muscles, the round ligament, and Pou- 
part's ligament. The last loop, in addition, penetrates the outer 
pillar of the external ring, and emerges upon the outer surface of 
the external oblique aponeurosis at the lower end and outer side of 



306 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



the fascial wound. A stitch is then taken with still the same strand 
of silk, piercing the internal pillar of the external ring, round liga- 

Fig. 184. Fig. 185. 





Deep tier of suture drawn home, obliterating ingui- 
nal cana! :s.,skin ; s. c./., subcutaneous fat ; a.e.o., 
aponeurosis of external oblique; i.o., internal 
oblique; P.I., Poupart's ligament. 



Superficial tier of buried suture of forty-day 
catgut closing incision through aponeuro- 
sis of external oblique, restoring anterior 
wall of canal. The excess of round liga- 
ment has been cut away just outside of 
external ring. The part protruding through 
ring, together with pillars of external ring, 
pierced by lowest loop of superficial suture. 
Loose knot at upper end shows proper way 
of tying buried catgut knot to preventslip- 
ping. Skin and fat to be closed, all by a 
subcutaneous catgut suture : s., skin ; s. c.f., 
subcutaneous fat; a.e.o., aponeurosis of ex- 
ternal oblique ; r.L, round ligament. 



ment, and external pillar. The excess of round ligament is now 
cut away just outside of the external ring, leaving the stump to 
plug the ring. After thus obliterating the inguinal canal and clos- 
ing both internal and external rings, the same strand of silk is con- 
tinued upward as a running suture, uniting the lips of the incision 
in the external oblique aponeurosis and closing the anterior wall of 
the canal. The two free ends of the suture at the upper end of 
the wound are now tied. The skin is approximated over all by a 
superficial silkworm-gut or silk suture, and the wound closed with- 
out drainage. The ordinary dry sterile dressing used for all abdom- 
inal wounds is applied (see Technique). No pessary is at any time 
needed after the operation. 

The difficulties of the operation lie principally in the technique, 
and can all be overcome by practice : this is particularly so in the 
case of not being able to find the round ligament. Should the liga- 
ment break while drawing it out, it should be picked up at its ute- 
rine end and the operation proceeded with ; in case the end cannot 



DISTORTIONS AND MALPOSITIONS. 



307 



be readily found, the wounds are best closed and hysterorrhaphy per- 
formed. Subsequent hernia is practically the only after-result to 
be feared. 

Hysterrorhaphy or Ventro-suspension. — The procedure is essen- 
tially a suspension of the uterus from the abdominal wall. Silk- 
worm-gut is the preferable suture material, combining the advantages 
of silk and silver wire, while free from their drawbacks. The 
abdomen is opened as low down as possible, the incision being small. 
Trendelenburg's posture is of the greatest help, because the moment 
the abdomen is opened the pelvis can be emptied of bowels, thus 
eliminating the danger of injury to the intestines. When the 
abdomen is opened a careful inspection is made of the uterus and 
adnexa and the exact condition of the pelvic contents determined. 
Under the combined guidance of eye and touch existing adhesions 
are severed. In the majority of cases manipulation with two fingers 
will suffice to break up the adhesions. Old and very firm adhesions 
may require the assistance of the scissors or scalpel, care being taken 
that the rectum be not wounded. It is in just these cases, the diffi- 




Sutures in Position in Hysterorrhaphy. 



culties of which may not be foretold, that Trendelenberg's posture 
is of especial benefit ; the incision need not be longer than is re- 
quired in the horizontal posture. If the operation be attempted in 



308 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

the latter posture, the greatest annoyance is felt from the intestines 
slipping in between the fingers : intestines are thereby subjected to 
unnecessary and at times dangerous handling. Hemorrhage due to 
severing the adhesions is slight, as a rule. Should the capillary ooz- 
ing be at all disagreeable and collect in a pool in the cul-de-sac, a 
wad of antiseptic gauze may be introduced to exercise pressure and 
catch the blood. This is to be removed just before the sutures are 
tied. Very seldom will a ligature or stitch be necessary to control 
the trifling bleeding. Should such be required, it may preferably 
be of catgut. 

The uterus being freed and elevated, the adnexa are carefully 
inspected, if their exact condition has not already become apparent 
while releasing the uterus. Should they be the seat of disease, what- 
ever method of treating them is indicated is carried out. The ute- 
rus is lifted up into the wound and the exact site for the fixation of 
the womb is determined. A suture is passed through the entire 
abdominal wall of one side. The needle is again grasped in the 
needle-holder and passed superficially beneath the uterine serosa at 
a point a third of an inch posterior to the apex of the fundus uteri 
from side to side through a space a quarter of an inch in length. 
The needle is then passed through the abdominal layers of the other 
side, opposite the point of first introduction. A second suture is 
introduced in a similar manner about a quarter of an inch posterior 
to the first one. A full-curved bayonet-pointed needle is best used, 
one without a cutting edge. Unless a sharp needle be used the 
needle-punctures bleed but little. These two sutures are held by 
catch-forceps, and others introduced as usual to close the rest of the 
wound. Two sutures only pass through the uterine tissue. The 
uterine sutures are tied first, after which, if it be thought desirable, 
the patient may be lowered from Trendelenberg's posture, all danger 
of including gut between the uterus and parietes having passed 
when the sutures are tied. While tying the sutures, especially 
those which pass through the uterus, the peritoneum of the incision 
should carefully be approximated: and it is wise to leave the uterine 
sutures long for purposes of identification. It is advisable to scarify 
gentlv that part of the uterine surface which is to come next to the 
parietal peritoneum, in order to ensure sufficient plastic union be- 
tween the opposed surfaces. Dressings are applied in the usual 
manner. The sutures should be removed about the eighth day, but 
those through the uterus may remain three weeks or longer. Just 



DISTORTIONS AND MALPOSITIONS. 



$09 



before the removal of these latter the uterus should be held up by a 
vaginal tampon, which should be employed for several weeks longer. 
The objections made to the operation are — its possible rate of mor- 




Stitches in situ in the Abdominal Wall after IlystiTorrhaphy. Two lower sutures— the ones which pass 
into uterine tissue— are shotted. 

tality ; the production of a break in the ventral wall, with the pos- 
sibility of hernia ; the formation of a false band around which 
intestines may become caught ; the induced immobility of the organ 
and its effect upon a future pregnancy. None of these objections 
are pertinent when the bysterorrhaphy is done in a proper manner, 
but they become forcible when it is improperly performed. They 
may be considered separately. There is no rate of mortality inhe- 
rent in the operation, and it does not complicate other operative pro- 
cedures performed at the same time. The mortality attending it is 
that only of " accident," which is inherent in every operation which 
opens the abdominal cavity. The possibility of ventral hernia is 
undoubtedly attendant upon every operation in which the peritoneal 
cavity is opened by incision through the abdomen. This complica- 
tion occurs in inverse ratio to the care in the technique. The per- 



310 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

centage is exceedingly small. No case, so far as we know, has been 
reported where intestinal obstruction has been due to the adhesion 
between the uterus and ventral wall. 

It is essential to the future of the patient that a too firm fixation 
be not accomplished. The object aimed at should be to throw the 
fundus of the uterus into an anterior position. A slight suspending 
cord is all that is necessary to keep it there, the intra-abdominal 
pressure aiding in this. If the adhesion be a broad and firm one 
and pregnancy follows, considerable trouble may result. During 
gestation the posterior wall of the uterus develops alone, to the 
exclusion of the anterior wall, which remains fixed and undeveloped. 
At labor dystocias of all kinds have been noted, and Cesarean 
section has been necessitated in a number of instances, with not a 
few deaths. If the technique be a proper one, the point of adhesion 
posterior to the fundal apex, and the resulting band be long and 
thin, merely sufficient for support, but not for fixation, most if not 
all the dangers of the operation will be avoided. The union obtained 
by the method described is very tender, and, like other adhesions 
produced from serous surfaces, it is very elastic and prone to stretch. 
This is eminently so in regard to the uterus fixed in this position, 
for it not only has its own weight to bear, but also that of the 
entire abdominal contents when the pelvic floor tends to bulge 
under intra-abdominal pressure. Abortion has occurred in uteri 
so fixed. Pregnancy which has progressed to full term has been 
frequently reported. 

Prolapsus. 

Descent or prolapse of the uterus may be of any degree, from 
that of slight displacement, which accompanies a retroversion, to the 
complete, where the whole organ is below the pelvic outlet. There- 
fore any explanation of the amount of descent must be descriptive, 
and the condition cannot be divided into first, second and third 
degrees. 

As a very general rule, the condition occurs in women who have 
borne children, but it also occurs in nulliparae. In the two 
classes the affection is essentially different in etiology, pathology, 
and treatment. 

Complete and partial prolapse comes on gradually in most cases, 
but sudden efforts or effects, as lifting, being crushed, or falling from 



DISTORTIONS AND MALPOSITIONS. 311 

a height, may bring it on acutely by rupturing the round, utero- 
sacral, and broad ligaments. 

Pathology of Complete Peolapse. — The vagina is inverted. 
Its posterior wall is prevented from further descent by the sphincter 
ani. The anterior wall is checked in further descent by its attach- 
ment to the bladder, the latter doing this through its insertion at 
the symphysis. The epithelium of the vagina becomes thick- 

Fig. 188. 




Varieties of Prolapsus. 

ened and like cuticle. Continuous irritation against the thighs and 
clothing may produce local losses of tissue in the shape of irregular 
ulcers. The urethra is also drawn down and its canal is U-shaped. 
The uterus occupies the pouch of the inverted vagina, and both 
before and behind are culs-de-sac lined with peritoneum. Both are 
below the outlet of the pelvis. Further descent of the uterus is 
prevented by the anterior and posterior vaginal walls, by the utero- 
sacral ligaments, but still more by the broad ligaments. The round 
ligaments play but a small part in supporting the organ. 

The cervix is engorged from stasis, and its vaginal portion, being 
the lowest point of the tumor, may be ulcerated. According to the 
integrity of the external os, there may or may not be ectropion of 
the cervical mucous membrane. The uterine wall and mucosa are 
in the condition of chronic hypertrophic metritis and endometritis, 



312 



AN AMERICAN TEXT- BOOK OF GYNECOLOGY. 



both being thickened with the production of new connective-tissue 
elements. There is usually chronic urethritis from retention of the 
urine in the dilated and prolapsed urethra, and there may be chronic 
cystitis. The cul-de-sac between uterus and bladder and the utero- 

Fig. 189. 




Vertical Mesial Section of Prolapsus Uteri : u, uterus ; B, bladder; V, anterior vaginal wall ; V", posterior 
vaginal wall ; S, pubic bone ; A, posterior peritoneal pouch ; p, anterior peritoneal pouch. 

rectal pouch may be occupied by intestines ; and the ovaries and 
tubes lie on top of the fundus. Tension on the broad ligaments 
produces obstruction in the ureters, and inflammatory conditions, 
even hydronephrosis, may result. In very old cases marked atrophy 
of the uterus may ensue. 

The condition is essentially that of hernia through the pelvic 
floor. Continuous irritation of the cervix of the prolapsed uterus 
existing for years may even produce epithelioma. Torsion of the 
broad ligaments produces varicocele in the pampiniform plexus. 
Irritation of the protruding mass has caused acute swelling, with 
rapid spread of the ulcerations and all the symptoms of strangula- 
tion with attendant difficulty of replacement. Anesthesia is then 



DISTORTIONS AND MALPOSITIONS. 



313 



advisable for reduction, and possibly abdominal section may become 
necessary. If failure at reduction results, vaginal hysterectomy 
may be demanded. 

Causes. — The starting-point of all cases of prolapse is a break 
in the pelvic floor, or relaxation of the uterine ligaments, or 
increased weight of the uterus, or all combined. With any one 
of these factors present an increase in intra-abdominal pressure 

Fig. 190. 




Complete Prolapse of the Uterus : a, cervical canal ; b,b, superior portion of the vagina, which is now the 
inferior; c,c,c, mucous surface of anterior wall of the vagina; d, urinary meatus; e,e, probe passed 
vertically into the former neck of the bladder, to show the total turning inside out of that organ; /, 
ulceration of the vaginal mucous membrane. 

will produce descent of the uterus. Although the ligaments may 
for a time return the organ to its normal position after such effort, 
yet the continuous strain will in time produce the permanent lesion. 

Thus it is that we find the condition following labor, or resulting 
from a neoplasm, or associated with subinvolution and supravaginal 
hypertrophy of the cervix. 

Tears in the pelvic floor should warn us against too early resump- 
tion of duty after labor. For involution of the uterus alone is 
not all that is necessary, but the elongated ligaments and generally 
enlarged parturient canal must also shrink, that the organ may 
have proper support. 



314 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



Rupture of the perineum more than any one other lesion con- 
duces to prolapse, and in the following way : The parturient woman 
is naturally inclined to constipation from the very nature of her 
weakened condition. In attempting to force out the stool by strain- 




ing the break in the pelvic floor allows of the escape of a good deal 
of force, and she has to bear down very hard. As she forces the 
stool down, it does not have the resistance of the perineum, which 
would naturally direct it backward through the sphincter. The 
levator ani, which is the muscle opposed in its action to the sphinc- 
ter ani, and which dilates the latter, being torn, the sphincter cannot 
dilate normally, but rather closes more tightly. The stool there- 
fore meets this muscle contracted, and, the pressure still continuing, 
the contents of the bowel bulge out the rectum into the lumen of 
the vagina, thereby producing a rectocele. In doing this the poste- 
rior vaginal wall is drawn down, and it, in turn, pulls on the cervix. 
In front of the uterus is the thick-walled bladder, preventing its 
forward movement: therefore it is pulled backward. This traction, 
together with the steadily-increasing intra-abdominal pressure which 
the woman keeps up to force out the feces, produces both retrover- 



DISTORTIONS AND MALPOSITIONS. 315 

sion and descent. The bowel being emptied, the pressure subsides, 
and the elasticity of the tissues draws up the displaced organs. 

Fig. 192. 




The arrow shows the direction of force in the case of a normal perineum when straining at stool. The 
thick perineum resists, and the fecal matter is consequently forced in the line of the anus and a nor- 
mal passage secured. 

Frequent repetitions of this, together with other acts which in- 
crease this intra-abdominal pressure, gradually bring about the 
condition described as prolapse. The rectocele is the first pouch 
of tissue to appear, as a rule. Following upon this rectocele, the 

Fig. 193. 




The perineum being ruptured no longer resists the force of straining at stool, but is pushed by the 
advancing fecal matter until it begins to protrude from the vulval orilice. The result is constipation 
and progressive formation of a rectocele. 

uterus having descended somewhat, comes the anterior vaginal wall, 
producing a cystocele. In this anterior pouch is contained more or 



316 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

less of the bladder. Cystocele occasionally occurs before the recto- 
eel e, but when it does so it is the result of tears of the anterior wall 
during delivery. So great has become the desire in forceps and 
other difficult deliveries to avoid wounding the perineum that the 
tissues just beneath the symphysis are subjected to much dragging 
force, resulting in tears to one or the other side of the urethra. 




The urethra may even be loosened from its attachments to the sym- 
physis. It is in this way that so great a laxity of attachment of 
the anterior vaginal wall to the bladder and symphysis is produced 
as to cause the appearance of cystocele before rectocele ensues. From 
what has been said the importance of easy evacuation of the bowels 
by enemata without straining, whenever the perineum is torn, 
must be apparent. When the axis of the uterus has become coin- 
cident with that of the vagina the intra-abdominal pressure bears 
directly upon the uterus continuously, in a direction which tends 
to force it out. It must not be forgotten that in its normal posi- 
tion over the bladder, the intra-abdominal pressure is behind the 
uterus as well as above it, and tends to force it forward. In other 
words, it supports the organ. 

When the cystocele has become at all marked, dysuria is pres- 



DISTORTIONS AND MALPOSITIONS. 



317 



ent, and considerable effort must be employed to empty the 
bladder. Thus another cause for increasing the cystocele is gen- 
erated. Complete evacuation of the bladder becomes impossible ; 
a little urine is retained and decomposes ; an irritable and inflamed 
condition ensues at the neck of the bladder, followed by ardor urinse. 
As the cystocele increases in size the neck of the uterus is pulled 
upon more and more and the descent of the whole organ facilitated. 
Thus it is that, when once the prolapse is accompanied by cystocele 
and rectocele, these conditions become causes for such efforts to 
empty the bowel and bladder as to still further add to the descent. 
The mechanism of the pelvic floor is very simple and easily under- 
stood. The practical difference in the pelvic floor between the male 
and female is the additional break in the latter by the vaginal canal. 
Nature has guarded this very well by surrounding the whole lower 
third of the vagina with the levator ani muscle and its fascias. In its 
action this muscle, when contracting, closes the vagina, lifts the peri- 
neum, and pulls apart the fibres of the sphincter ani if the latter be 
relaxed. The combined action of both muscles is to close the pelvic 
outlet entirely. Whenever a nulliparous woman tightens her belly 
and diaphragm, the pelvic muscles contract involuntarily, as in the 





Showing effect of intra-abdominal pressure on 
uterus in anteflexion with intact pelvic 
floor. 



Pelvic Floor broken down, Uterus in retroflex- 
ion. The intra-abdominal pressure now 
increases the displacement and ends finally 
in prolapsus. 



various movements of the body. When such a woman defecates, 
the sphincter relaxes, the levator contracts and closes the vaginal 
cleft, while the rectal is open, thus preventing any marked descent 
of the uterus. There is a very sufficient correlation between the 
actions of the two muscles. There are other supplementary but 



318 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

unimportant perineal muscles. The levator ani is covered by a 
sheet of the pelvic fascia, known as the obturator fascia, which 
gives it great strength. 

When the fibres of this fascia and muscle are separated as in 
laceration of the perineum, their ends retract gradually toward 
the ischial rami of either side, producing the " angles " or " sulci " 
spoken of in articles on perineorrhaphy. The older the case the 
more marked is this retraction. As the rectocele comes down it 
pushes out between these separated fibres. 

A woman with ruptured perineum on defecating relaxes the 



Illustrating the Formation of a Complete Prolapsus, 



sphincter, but the levator fibres are torn asunder, and their dilat- 
ing action upon the sphincter is gone. She has to strain, and as 
she does so the vagina can no longer be closed by the levator, but 
the rent allows the intra-abdominal pressure and the advancing 
feces to force the posterior vaginal wall out of the vulval orifice, 
producing a rectocele. In this way, is prolapsus produced. The 
condition is rightly described as a hernia through the pelvic floor. 
The result is produced gradually, sometimes taking many years to 
become fully developed. 

The first step in prolapsus is a retroposition of the organ. As 
this increases rectocele supervenes, and in a short time cystocele. 
When the uterus has descended to the vulva, it loses its retroposed 
position through its attachment to the bladder, becomes more erect, 
and is pulled toward the symphysis. On escaping from the body 
it occupies a position in the centre of the sac. After a certain 



DISTORTIONS AND MALPOSITIONS. 319 

amount of descent has taken place retarded venous circulation 
causes the organ to enlarge, and still more contributes to prolapse. 

Symptoms. — In acute prolapse there are the symptoms of great 
shock, signs of internal hemorrhage perhaps, and severe pelvic 
pain. This condition is rarely seen. Examination will readily 
demonstrate the lesion. 

The uterus is found at o-r outside the vulva, covered with the 
anterior or posterior wall of the vagina, according as it was anteverted 
or retroverted before the accident. The parts are livid from venous 
stasis, due to pressure on the thin-walled veins in the tense broad 
ligaments. The patient is usually unable to urinate, owing to dis- 
tortion of the urethral canal and pressure upon it by the displaced 
organ. The bearing-down pain amounts to agony. 

In chronic prolapse, coming on gradually, the first symptoms are 
those of backache, bearing-down or tenesmus, shooting pains from 
rectum to bladder, costiveness, dysuria, pains radiating down the 
thighs, and absolute inability to walk ; and yet a complete pro- 
lapse of many years' standing may produce no effect upon the 
woman, she merely complaining of the inconvenience of the mass. 
There may be symptoms of kidney disease from obstruction in 
the ureters, and the peritoneum is often involved in old cases. The 
erosions which occur produce an annoying discharge. The uterine 
walls are thickened, but the endometrium is not markedly changed. 
Menstruation seems as often decreased as increased, due in part, 
probably, to the fact that most cases occur about or after the meno- 
pause. Cystitis is not uncommon, due to incomplete evacuation of 
the bladder. The costiveness, the continual straining at stool, and 
the use of evacuants produce a proctitis, which may lead to the sup- 
position of the existence of rectal disease only. Objectively, a 
tumor is found projecting from the vulva and attached to the mar- 
gins of the pelvic outlet, and more or less pear-shaped with the base 
up. At its apex is found the os externum, into which the probe 
readily enters. As demonstrating the importance of drainage from 
the uterus, it may be mentioned that these cases, though subjected 
to much examination at many hands and exposed to all sorts of filth, 
seldom present the changes of septic endometritis, so perfect is the 
escape of the discharges. 

If intestines be prolapsed into the posterior cul-de-sac, there may 
be a tympanitic percussion note at the upper border of the tumor 
behind. 



320 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

Usually, the tumor may readily be reduced en masse, and as 
readily comes down again. The sound in the urethra follows down 
the auterior wall of the tumor for a distance. With the sound in 
the bladder and finger in the rectum the two meet without the inter- 
position of the uterus, and the finger demonstrates that organ in its 
new position with the broad ligaments as tense lateral suspensory 
bands. In using the sound in the uterus it must not be forgotten 
that cases of pregnancy in the prolapsed uterus are not rare. Even 
ectopic gestation has occurred with complete prolapse. Occasionally 
the sound will show the uterus to be in a retroflexed position in the sac. 
The urine has an ammoniacal odor in such cases. In long-standing- 
cases incontinence of urine may come on, the bladder remaining 
partly filled all the time. Not infrequently the patient is forced 
to reduce the prolapsed mass and retain it in the vagina by means 
of her fingers before she is able to empty either the bowels or 
bladder. 

Less descent of the organ than the above description pictures, 
has been by authors divided into two degrees — the first when the 
cervix is above the vulval orifice, and the second degree when it 
appears at or engages in the vulva. They class complete prolapse 
as of the third degree. There is some convenience in this classi- 
fication, but it is entirely arbitrary. In examining these cases of 
lesser prolapse, the patient lying on her back, the uterus recedes 
quite a distance into the pelvis. But by causing her to bear down, 
she can readily cause the rectocele and cystocele to appear. Neo- 
plasms and ascites may cause descent if the pelvic floor be not 
intact. 

Diagnosis. — Inversion, polypus, and infra-vaginal elongation of 
the cervix uteri might be mistaken for prolapse. In inversion there 
is absence of the cervical canal and presence of the two lateral 
openings of the tubes at the base of the tumor. The protruding 
mass is encircled at its highest point by the cervix, presenting the 
same appearance as though the mass were a polypoid tumor pro- 
truding from the cervical canal: in no direction around the protrud- 
ing mass can the finger be passed into the uterus, but meets with an 
uninterrupted ring of obstruction. A finger in the rectum will 
reveal the fundus uteri absent from its normal position and the cup- 
shaped depression in the intra-pelvic cervix. A polypus hanging 
from the cervix or protruding through the os presents the cervical 
opening above the tumor. The fundus uteri will be found in its 



DISTORTIONS AND 3IALP0SITI0NS. 321 

normal position. At some point about the pedicle the finger can 
be passed up into the cervical canal, and even into the uterine 
cavity. 

Strangulation of the prolapse may occur when the vulval orifice 
is small, the organ coming out easily enough, but so swelling from 
stasis as to endanger its vitality. 

The Prognosis is excellent, both as to relief of the symptoms by 
palliative treatment and as to the result of operative procedures. 

Treatment. — It having been ascertained that by taxis the 
hernia can be reduced, retention in its proper position becomes our 
object. There are two means by which this may be accomplished. 
Certain patients will not submit to operation until every other 
known means has been tried ; and in some very feeble and old 
patients operation is impossible. In employing mechanical sup- 
ports they should be so used as to produce as little irritation as 
possible. They must hold up the displaced organs against not 
only their own weight, but also against the entire intra-abdominal 
pressure. No support should be used while there are ulcerations. 
These latter are best treated by applications of iodine, the displace- 
ment reduced, the vagina filled with iodoform gauze, and a tight 
T-bandage applied ; or by reducing the displacement, dusting the 
vagina with boracic acid, and packing it with borated cotton. 
Having cured the ulcerations and erosions, choice may be made of 
a means of support. Hard pessaries must take their points oVappui 
from some bony prominence, as the natural curves of the vagina are 
lost and the canal is perfectly straight, incapable of retaining any 
pessary against the force of the intra-abdominal pressure. The 
only pessary which can be of any use in complete chronic prolapse 
is the cup pessary supported externally by a belt about the waist. 
This should be removed at night and a boracic-acid vaginal douche 
taken. Where this cannot be worn a good substitute is Braun's 
colpeurynter. It takes its point of support evenly from all parts 
of the pelvic outlet. Before introduction it should be thoroughly 
cleansed, the vagina washed with boracic-acid solution, and the 
bag covered by zinc ointment, Being of soft rubber, it has a 
tendency to excoriate the moist parts unless greased. In some 
patients the bowels and bladder functions continue with the inflated 
bag in position. The instrument retains the organs in a high 
position. About an ounce of water should be introduced into the 
colpeurynter, and the rest of the distention made with air. The 



322 



AN AMERICAN TEXT- BO OK OF GYNECOLOGY. 



water is merely to fill the tube when the patient is up, and thus pre- 
vent the escape of air with collapse of the bag. 

The detail of the treatment of the cases of partial prolapse is 




Tamponade of Vagi 



Uterus, in the Knee-rlK'.sl Position. 



practically an enumeration of every known pessary and support, the 
physician trying one after another until one be found to suit the 
case or all fail. 

Patients may experiment with hollow rubber balls until one is 




Braun's Colpeurynter. 



found which will remain in the vagina and keep the uterus within 
the pelvis. It should be removed each night and cleansed, to 
be introduced in the morning before rising. 

Posture bus a marked effect upon the size of the uterus, and 



DISTORTIONS AND MALPOSITIONS. 323 

before any operation is done the woman, if possible, should be kept 
on her back with the head low, the uterus retained within the body, 
for from ten to fourteen days. During this time also the general 
functions may be gotten into good condition. 

Operative procedures devised and tried are about as numerous 
as pessaries. The whole question has now narrowed down to a con- 
sideration of the best means to unite the levator ani fibres and obtu- 
rator fascia of the two sides across the vagina at their original points 
of juncture, thus narrowing the vaginal canal and restoring its 
proper resisting power, to bring about involution of the usually 
enlarged uterus, and to hold the uterus upward and forward. 

If the descent be due to polypi or other conditions which render 
the uterus heavy and enlarged, such must be . removed by the ope- 
rative procedure appropriate to each. 

A curettage is of value as a derivative, thus contributing to dim- 
inution in the size of the organ, whether there be endometritis or 
not. Amputation of the cervix uteri or Emmet's trachelorrhaphy, 
as the cervical condition may indicate according to whether it be 
greatly hypertrophied or lacerated, is a necessary step in the pro- 
cess of repair. 

Posteriorly, that operation must be applied which pushes up the 
rectocele, narrows the posterior wall, and best approximates the 
separate ends of the levator ani muscle and obturator fascia of the 
two sides. Operations which drag down or fix the rectocele in situ 
are to be avoided. Amongst the preferable operations is Emmet's. 
Upon the anterior wall Sims' anterior colporrhaphy is indicated. 
These operations should be performed at one sitting. Good 
results are obtained in all degrees of prolapse by a combination of 
Hegar's colpo-perineorrhaphy and Sims' operation on the anterior 
wall. 

While in moderate or comparatively recent degrees of prolapse 
curettage, amputation of the cervix, and repair of the pelvic outlet 
may so reduce the descent as to symptomatically cure the patients, 
still in the more pronounced forms of the lesion permanent benefit 
cannot be expected from those procedures only ; they must be sup- 
plemented by hysterorrhaphy. In performing hysterorrhaphy under 
these circumstances an exception is made to the rule laid down when 
the operation is to be done for retro-displacements. Now the object 
should be to obtain a broad and firm adhesion of the uterus to the 
abdominal wall. For this reason the sutures are passed through the 



324 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

uterus from coruu to cornu, dipping down deeply into the muscu- 
lar substance of that organ. It is best to place these sutures so that 
they do not penetrate all the tissues of the abdominal wall, but only 
the peritoneum, muscles, and deep fascia, the free ends coming out 
on the surface of the fascia. The ends are securely tied together, and 
when the abdominal walls are approximated remain buried. The 
sutures should be of silkworm-gut. 

Freund's Operation. — In a certain limited number of cases 
which have passed the menopause, and in whom genital atrophy 
has begun, the operator may apply the procedure devised by Freund. 
But this operation is indicated only when it is deemed unwise to 
attempt plastic work, and where it is inadvisable to keep the patient 
in bed for any length of time. 

Under narcosis the uterus is curetted and irrigated, but not 
packed. The uterus is left in a prolapsed position. Upon one side 
of the vagina about half an inch below (above while the prolapse 
is present) the cervix the operator makes a short incision through 
the vaginal mucosa. A stout half-curved needle is threaded with 
silk to carry silver wire. The needle is introduced into the cut and 
made to completely encircle the vagina, and is brought out at the 
point of entry. To it is now attached a strand of silver wire (No. 
24), and this is drawn beneath the vaginal mucosa. 

Half an inch lower down another incision is made in the vagina 
and another wire suture drawn beneath the mucous membrane. The 
procedure is repeated at equal distances until the vulvar orifice is 
reached. The lowest (highest while the prolapse exists) suture is 
within the vagina entirely, and is at least half an inch internal to 
the meatus urinarius. The sutures are half an inch apart, and all 
lie entirely beneath the mucosa. If possible, the operator should 
avoid traversing the mucous membrane, but his needle should pass 
beneath it. It is commonly necessary, because the needle cannot be 
made to entirely encircle the vagina at one sweep, to withdraw the 
needle twice for each suture ; it should be reintroduced precisely in 
the aperture of exit. When all the sutures are in place the cervix 
is replaced sufficiently to tighten the suture nearest the cervix. 
When the proper degree of tension is secured the wire is closely 
twisted and the ends cut off outside the fourth turn of the twist. 
The twisted end is sharply bent and is tucked beneath the edges of 
the lateral incision. The uterus is further replaced, the second loop 
of wire is tightened so as to sufficiently pucker the vagina, the ends 



DISTORTIONS AND MALPOSITIONS. 325 

twisted, cut short, and tucked beneath the edges of the short lateral 
cut. In this way, progressively replacing the prolapsed organ and 
securing the wire loops, the operator completes the operation. The 
vagina is irrigated with boric- acid solution and a loose filament of 
iodoform gauze is introduced. This is removed in two days and the 
vagina again washed out. The patient is allowed out of bed for a 
few hours after six days. 

The success of this operation depends upon the degree of tension 
produced by each suture. The suture nearest the cervix should 
draw the vaginal walls together, so that the little finger will pass 
readily. The next suture will admit of the passage of the index 
finger, while the suture nearest the vulva constricts the vagina only 
sufficiently to furnish support to those above. The operation seeks 




P, pubis ; c, cervix ; 1, 2, 3, i. the wire sutures circling the 
vagina. Both ends are shown protrudim: from the short lateral incision* in the vagina ready to be 
tightened and twisted. They are introduced and twisted in the order of their numbers. 

the establishment of four permanent submucous silver-wire ring 
pessaries. The sutures are never removed. They should at least 
remain in place long enough to cause the formation of rings of con- 
nective tissue around the vagina. If the operator has succeeded in 
applying his sutures tightly enough to afford to each other mutual 
support, and yet not so tightly as to cause them to cut through, he 
will have the satisfaction of seeing his patient relieved of this most 
distressing condition. Coition is to be absolutely forbidden and 
laborious work avoided. The lateral incisions are preferable to 
those either upon the anterior or posterior wall, for with the first 
the wire knots will not lie beneath either movable hollow viscus, the 
bladder or rectum. The operation consumes about fifteen minutes. 
Acute prolapse rarely occurs alone, but associated with it are 
other injuries produced by the same violence. It is to be treated 



326 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

by gently returning the organ and packing the vagina lightly with 
cotton or gauze. An ice-bag to the suprapubic region will limit 
pain and bleeding. Symptoms of internal bleeding from ruptured 
ligaments should be treated by putting the patient at rest and by 
saline transfusion. 

In old women, who may not expect conception, the preferable 
procedure is either Freund's operation or extirpation of the organ. 
The uterus may be removed per vaginam much more rapidly and 
with less risk to these patients than if tedious plastic work be done. 

The operation should be performed with ligatures, and the stumps 
fastened into the vaginal opening, so as to draw the vagina upward 
during the process of contraction and repair, and give that organ a 
permanent support from above, which can be obtained in no other 
way. 

The danger to very old women lies largely in prolonged etheriza- 
tion necessary to plastic work of this extent. This is not the case 
with the rapid hysterectomy. 

Not a few failures occur in the hands of every operator to effect 
a cure in certain cases of complete prolapse. Where this has occurred, 
or in such cases as, in the opinion of the surgeon (based on experi- 
ence), it is liable to occur, the operation proposed by Baldy is to be 
performed. The class of cases to which this method is applicable 
is limited to women in whom the question of future childbearing is 
eliminated. Other than the mortality incident to an uncomplicated 
hysterectomy there is no danger. 

Baldy's Operation. — A glance at the accompanying diagrams 
will disclose what is proposed. 

The procedure is in all essentials an abdominal hysterectomy by 
amputation at or below the internal os. The points to be observed 
are — 

To include both the ovarian arteries and the round ligament in 
the first ligature on each side of the uterus. 

To place this ligature as near the pelvic wall as possible, so as 
to leave but a small amount or* broad ligament behind with the 
stump. 

To place but one other ligature on each side of the uterus, this 
ligature to include the uterine artery with as little other tissue as 
possible. This leaves both broad ligaments open. 

To amputate the uterus as low on the cervix as possible. 

Fig. 201 shows this part of the operation completed, together 



DISTORTIONS AND MALPOSITIONS. 



327 



with the second step — namely, the placing of the sutures. A glance 
at this illustration shows the suture in situ, while a glance at Fig. 
202 shows the suture tied with the parts drawn into place. 

It will be noted first that the suture is composed of heavy liga- 
ture silk — that in the course of its application it includes both the 
ovarian and uterine stumps, deeply placed well back of the ligatures. 
These points are important, as considerable traction occurs when the 
sutures are tied, and unless these precautions were taken, the suture 
might tear out or the ligature on the stumps become displaced. 

Fig. 201. 




Uterus amputated. Ligatures in place ready for tying. 

It will be further noted that the sutures include the sides of the 
cervical stump. 

It can readily be seen that the effect of tying these sutures is to 
lift up the stump of the cervix together with the vagina, and to 
bring it in close approximation with the ovarian stumps, doubling 
the opened broad ligaments together, as shown by Fig. 202. 

Of course the portion of the broad ligament at the point of the 
ovarian stump will be drawn down somewhat, bat the main effect 
is to lift to a high point the cervical stump and at the same time to 
drag up the vagina. Adhesions take place throughout the full 
extent of the doubled broad ligament, and most surprisingly firm 
support is given from above to the vagina. 



328 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



Fig. 203 shows the peritoneum drawn together by a catgut suture 
over that portion of the cervical stump which remains uncovered 
after the two sutures are tied. The abdominal incision is closed in 
the usual manner and the usual dressings applied. 

The result of the operation is as near perfect as is possible by any 
operative procedure. 

The results accomplished are — 

The weight of the heavy uterus is removed. 




Ligatures tied ; lifting up cervical stump: approximating cervical slump and ovarian stumps. 
Broad ligament doubled upon itself, burying uterine stumps. 

The over-stretched vagina is lifted high up and held firmly in 
place. 

The supports utilized are the natural supports of the uterus and 
upper portion of the vagina — the broad ligaments. 

The cervix remains a pelvic organ, as is natural to it. 

The immediate and remote result as regards fixation of the upper 
part of the vagina is perfect. 

The plastic operations on the vagina already recommended are 
absolutely essential as an adjunct to this as well as to any other 
similar procedure, for the reason that unless we remove the causes 
which produced the original prolapse we can hardly hope to escape 
a relapse, however well the work above may be conceived and exe- 
cuted. 

In cancerous or tubercular disease of the uterus the operation 



DISTORTIONS AND MALPOSITIONS. 329 

may be varied by performing a pan-hysterectomy. The vaginal 
mucous membrane is to be whipped together, closing off the vagina. 
The cut edges of the broad ligaments should be whipped together 
on both sides down to the former site of the cervix. The raw sur- 

Fig. 203. 





Peritoneum whipped over all, closing the wounds outside the peritoneal cavity. 

face at this point can then be brought up and fastened to the 
abdominal wall in a similar manner as when the cervix was 
not removed. 

This operation may be performed in any case which necessitates 
either a double ovariotomy or a hysterectomy, complete or incom- 
plete, when in the opinion of the operator a subsequent prolapse of 
the vaginal vault may occur. 

Another and excellent modification of this operation is, after the 
uterus has been removed by amputation at or below the internal os 
to fix the cervical stump to the abdominal wall at the lower angle 
of the abdominal incision by means of two silkworm-gut sutures 
passed through the full width of the cervix from side to side, and 
the free ends brought through the peritoneum, muscles, and deep 
fascia of the abdominal wall, where they are securely tied together, 
cut off short, and the knot buried when the incision is closed. The 
opened broad ligaments should be closed by a continuous catgut 
suture on each side, preferably before the cervix is anchored by its 
fixation sutures. The abdominal wound is then to be closed in the 
usual manner. This operation is to be chosen when a very large 



330 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

Fig. 204. 




Fixation nf Cervical stump to Abdominal Wall after Hysterectomy. Heavy lines, a, a, and b, b, indicate 
sutures pas.sin.ir into fascia, through muscle and peritoneum, thence through the amputated stump 
of the cervix, and finally through the peritoneum, muscle, and fascia of the opposite side. Light 
lines indicate sutures to c\t»v abdominal wound. 

amount of relaxation exists, and the vaginal vault would not other- 
wise be lifted up sufficiently high to give the requisite support. 

Supravaginal Hypertrophy of the Cervix. 

The exact causes of this condition are unknown. It will be 
remembered that in early infancy the cervix alone exists, there 
being no corpus. It is possible that some excitant gives the cervix 
a false start about puberty, and it grows in an entirely dispropor- 
tionate degree. The condition is to be distinguished from the other 
forms of cervical hypertrophy already described. It is charac- 
terized by an inordinate hypertrophy of that portion of the cervix 
which is attached to the bladder. So great is this hypertrophy that 
the increased weight of the uterus causes it to prolapse. The con- 
dition is peculiar to the nulliparous or primiparous, and is only occa- 
sionally found in women who have borne children. With the excep- 
tion of acute prolapse produced by violence, this is the only form found 
in nulliparous women. The uterus descends because of its great 
weight. As it comes down displacement of the upper part of the 
vagina takes place first, whereas in the prolapse of the multiparous 
the rectocele and cystocele precede the descent of the uterus. When 
the prolapse has become complete so that the entire vagina is turned 
inside out, yet will a part of the fundus remain within the pelvic 
cavity. The essential pathological condition is one of hypertrophy 
of the cervix above its insertion into the vagina. This is not due 
to inflammatory action, but is rather an excess of normal elements. 



DISTORTIONS AND MALPOSITIONS. 331 

The changes in the vagina and bladder are here the same as in the 
other form of prolapse. Owing to the small size of the vulva the 
tumor is constricted above at first, but in long-standing cases the 
vulvar orifice is fully distended. The base of the tumor is above, 
the apex below. The sound in the urethra and finger in the rec- 
tum show that the corpus lies between. The sound in the uterus 
will demonstrate its great length. As the patient lies on her back 
the marked difference in shape between the two kinds of prolapse 
becomes apparent. Here the pelvic floor is intact, and there is no 
true rectocele, no redundant vagina. Consequently there is absence 
of that puffy ending to the mass which is observed in the prolapse 
of multiparas. In prolapse due to cervical hypertrophy the vaginal 
walls leave the cervix at an acute angle. The cervix is not lace- 
rated, but rather conical. 

Symptoms.— These are the same as those of the other forms of 
chronic prolapse. Reduction is not as easy as in true prolapse, ow- 
ing to the greater amount of uterine tissue relative to the size of the 
vagina, and complete replacement within the body to the length of 
the vagina is not usually possible. Straining does not materially 
increase the displacement, and, conversely, the dorsal decubitus does 
not lessen it. The general mobility is less than in true prolapse. 
The physical characteristics are stated above. 

Treatment. — This must remain purely of a surgical nature. 
Palliative measures which afford relief in true prolapse are here 
useless. The cervix must be removed by high amputation as de- 
scribed in the chapter on Malignancy, so that sufficient tissue may 
be taken away. While the wound is healing the uterus must be 
kept in the pelvis by vaginal tamponade of gauze. After the union 
is firm and the sutures are removed the anterior and posterior walls 
may be narrowed by making on each an oval denudation. The 
immediate decrease in size obtained does not represent the ultimate 
decrease, for involution of the organ proceeds some time after the 
operation of amputation, and the uterus continues for some time to 
get lighter and smaller. If necessary at a subsequent time hysteror- 
rhaphy may be performed. 

Infra vaginal Elongation of the Cervix Uteri. 

Infravaginal elongation of the neck of the uterus occurs as a 
complication of prolapsed uteri, of lacerations of the cervix, and 



332 AN AMERICAN TEXT-BOOK OE GYNECOLOGY. 

as a congenital condition. The elongation in the first two varieties 
is merely apparent, and will not be considered. 

In prolapsus, as the uterus descends, the vaginal vault folds back 
over the supravaginal portion of the cervix and gives it the appear- 
ance of actual elongation. By placing the patient in the knee-chest 
position the uterus falls back into the pelvic cavity, the uterus and 
vagina assume their natural relations, and the apparent elongation 
of the cervix disappears, showing at once the true condition. 

In lacerations of the cervix one lip is oftentimes partially absorbed 
and everted, giving the cervix the appearance of being elongated. 

Congenital elongation of the cervix is comparatively rare. The 
narrow conical cervix of a non-fully-developed uterus is often mis- 
taken for this condition. Such a cervix is really not elongated, but 
is seemingly so from its peculiarly narrow, tapering shape. 

A true elongation of the cervix is always congenital. It may 
consist of an increase in length from half an inch to a protrusion 
from the vulvar orifice. Frequently the examining finger comes 
in contact with it immediately on passing into the vagina. 




Elongation of Infravaginal Portion of Cervix. 



The symptomatology consists wholly in sterility, unless the descent 
be sufficient for its protrusion into the vulva, when the presence of 
the tumor will usually be detected. Under these circumstances 
coition would materially be obstructed. The diagnosis is easy. 
It may be mistaken for a prolapse, an inversion, or a polypus. A 
digital examination of the vagina will show the tumor to be contin- 
uous with the true cervix, and in no way different from it. Inspec- 
tion as well as examination by the finger discloses the os. A biman- 
ual examination with the finger in the rectum will reveal the corpus 



DISTORTIONS AND MALPOSITIONS. 



333 



uteri in its normal relation and position and the vaginal mass per- 
fectly continuous with it. These points being ascertained, there can 
be no excuse for a mistaken conclusion. 

The treatment consists in a simple or wedge-shaped amputation 
of the cervix at a point about an inch from the vaginal attachments. 
A description of the operations will be found below. 

Plastic Operations. 

The partial extirpation of the cervix may be performed by two 
methods : either by a simple amputation of that part of the cervix 
projecting into the vagina or as a modified wedge-shaped excision. 

Simple amputation of the cervix is less desirable than that by the 
wedge-shaped excision, on account of the greater accompanying 




Simple Amputation of the Cervix, stitches in situ 



hemorrhage and the greater difficulty in covering the stump. The 
operation is performed as follows : The cervix is exposed by a peri- 
neal retractor and grasped by a double tenaculum or volsellum for- 
ceps. The labia are held apart by two other retractors, and the womb 
is then drawn down as far as the elasticity of the uterine ligament 
will permit. The farther this is possible the easier is the operation. 
Great care must be observed in applying traction, however, when 
inflammatory changes coexist in the adnexa. The mucous mem- 



334 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



brane is incised by a circular incision, and the cervix severed as far 
as the canal. Before the entire separation it is advisable to place 
one or two stitches in the severed wall, leaving the ends long. 
These control the bleeding and act as tractors after the cervix has 
been completely severed. Tractors are applied by some operators 
before beginning the operation by passing a strong silk thread 




Simple Amputation of the Cervix, stitches tied. 



through the cervix above the field of amputation. The womb is 
now held fast by the tractor, the separation completed, and the 
sutures quickly placed, radiating from the cervical canal like the 
spokes of a wheel. The union of the two mucous surfaces over the 
stump is facilitated if the needle be introduced in the cervical mucosa, 
brought out midway between the cervical mucosa and the vaginal 
mucosa, and again introduced through the vaginal mucosa. As the 
circumference of the circular edge of the vaginal mucous mem- 
brane is much larger than that of the mucous membrane of the 
cervical canal, and the tissues of the cervix are very hard and 
unyielding, exact coaptation and a smooth line of suture are never 
attained. The vaginal mucosa is always thrown into folds radiating 
from the cervical canal, but good union is ultimately obtained. 



DISTORTIONS AND MALPOSITIONS. 



335 



Wedge-shaped Amputation of the Cervix. — The uterus is curetted, 
irrigated, but not packed. Pulling the cervix down by means of 
one pair of bullet-forceps fastened into the centre of the anterior 
lip and one pair in the posterior lip, the operator splits the cervix 



Fig. 208. 




Profile of the Wedge-shaped Amputation of the Cervix Uteri, sutures in place. 

from side to side. The cut extends from the internal os, or a little 
higher than the amputation is to go, out upon each side to the vag- 
inal junction. This produces two flaps, an anterior and a posterior. 
Upon the anterior flap, at a point as high as the amputation of the 
raucous membrane of the cervix is to extend, the operator cuts into 
this flap for a depth of a quarter of an inch across the entire face of 
the flap. The knife is now drawn across the vaginal face of the 
anterior flap, and this cut is made to reach the bottom of the first. 
By this last procedure a wedge is removed from the anterior flap, 
and the anterior is converted into a double flap with a shorter por- 
tion or " bench," made by the first cut, and a larger portion com- 
posed of the unamputated part of the anterior flap. 

The same maneuvre is employed upon the posterior flap. 

A needle is now entered upon the anterior flap at the centre of 
the cervical canal, passing entirely beneath the " bench." It is 



336 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



withdrawn, and is inserted into the raw surface of the anterior flap, 
and emerges at the edge of the vaginal covering of this portion. 




Profile of the Wedge-shaped Amputation of the Cervix Uteri, sutures ready to tie. 



Two more sutures are similarly passed, one upon each side of the 
first. When these sutures are tightened it will be seen that the vag- 



Fig. 210. 



Fig. 211. 





The cervix has been split bilaterally. and the 
anterior flap is held up. The knife is 
cutting the "bench" upon the anterior 
flap. (Sketched from nature.) 



The knife is amputating a portion of 
the anterior lip by a cut which 
joins t lie cut form ins the "bench." 
(Sketched from nature.) 



inal face of the anterior flap is folded over upon the anterior cervical 
mucous membrane. This makes provision for the anterior portion 



DISTORTIONS AND MALPOSITIONS. 



337 



of the future os externum. The same thing is done upon the pos- 
terior flap, and the entire new external os is made. It will now be 
seen that the lateral portions of both " benches " are redundant. 
These are cut away with scissors down to the bottom of the incision, 




The middle sutures have been inserted on the anterior lip, and the redundant " bench " at each angle is 
cut away. Upon the posterior lip the scissors are cutting away the excess of the "bench." 



so that at the angles there will remain but two smooth flaps, an 
anterior and a posterior. These are approximated by sutures passed 
from before backward, each suture being entirely buried. In apply- 
ing these through-and-through sutures it may be necessary to bring 
the needle out several times at one sweep. The needle cannot em- 




shaped Amputation of the Cervix, sutures tied. 

brace all the tissue of both lips of the cervix. The first introduc- 
tion and withdrawal of the needle is shown in Fig. 212. 

When the operation is completed the appearance will be as shown 
in the illustration (Fig. 213). 

If, after completing the external os upon each lip, the " benches " 



338 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

were left undisturbed, the through-and-through sutures upon each 
side of the cervical canal would bring together four projections of 
tissue. To avoid this and limit the possibility of failure to get 
union, the benches upon each side of the canal are cut away as 
described. 

Having completed the operation and holding all the sutures to 
steady the cervix, the canal is gently dilated, the uterine cavity 
again washed out with salt solution, and packed with iodoform 
gauze. The sutures are now tied and their free ends cut off. The 
vagina is snugly packed with iodoform gauze. On the third day 
the vaginal dressing is removed and the uterine packing withdrawn. 
The uterus is not again packed, but the vagina is. 

The vaginal dressing is changed once in three days, and the 
sutures are removed in from ten days to three weeks. If the vul- 
var orifice be tight enough to retain the iodoform gauze dressing 
within the vagina, the patient is allowed out of bed in six days. 
But if there be risk of dropping the vaginal dressing, so that mo- 
bility of the uterus will follow, she had better remain in bed until 
the sutures are removed. 

The operator seeks to remove two-thirds of the hypertrophied 
vaginal portion of the cervix. He leaves none of the diseased tis- 
sues, cysts, etc. which trachelorrhaphy fails to remove, because of 
the necessity for leaving a central portion upon each lip which 
that operation requires in order that a cervical canal may be retained. 
Subsequent pregnancies progress normally so far as the cervix is 
concerned. It will be further noticed that this operation provides 
a cervical canal slit-like in form, and not a round tubular canal, 
such as is secured by trachelorrhaphy. Whenever there is much 
cervical hypertrophy of a chronic character, with or without lacer- 
ation, this operation is recommended. 

Where a purulent endometritis coexists with a degree of cervical 
disease necessitating an amputation, it is not wise to curette and 
amputate at the same sitting. Either the curettage should be done 
a week before the amputation, or the operator should control the 
endometritis by means of irrigation with large quantities of mild 
antiseptics, such as boric-acid solution, together with the use of 
gauze tamponade of the uterus, before doing the amputation. 

Anterior Colporrhaphy (Sims'). — A point just posterior to the 
urethra is marked, and another in front of the cervix. With tenac- 
ula the lateral walls of the vagina, midway between cervix and 



DISTORTIONS AND MALPOSITIONS. 



339 



urinary meatus, are brought together. If they can be approximated 
too readily, the tenacula should be placed farther to the sides. The 
object is to catch up the sides of the anterior vaginal wall at points 
which may be approximated without too much strain. These being 
determined, they are marked. The four points thus chosen are 
united by an oval line, the greatest diameter of which is at the 
middle of the vagina. But this rule is not invariable, and the 
greatest width may be made where there is the most slack. Den- 




c< 



Sims' Anterior Colporrhaphy, stitches in situ : A, urethra ; B, cervix. 



udation is made by cutting with scissors. The operation is exceed- 
ingly simple and easily performed. The sutures are catgut and are 
passed from side to side. A double row of continuous sutures is 
used, the first row being placed entirely within the denuded surface, 
narrowing it fully one-half and removing considerable of the tension 
on the row approximating the mucous-membrane edges. The sec- 
ond row brings the edges of the incision together, burying the 
former suture. This is the preferable operation when it is desired 
merely to narrow the vagina. It does not foreshorten it, as does 
Stoltz's operation. It is a valuable adjunct to other procedures 
adopted for repair of the pelvic floor and reduction in the calibre 
of the vagina. ■ 



340 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

Colpo-perineorrhaphy (Hegar). — The object of this operation is 
to unite the separated ends of the levator ani muscle and pelvic 
fascia, to push the rectocele upward, and to narrow the vagina. 
Although the surfaces denuded by this method do not resemble the 
freshly-torn perineum, yet it must not be overlooked that we deal 
with torn perinea when they have acquired two elements never pres- 
ent in fresh tears — viz. the rectocele and retraction of the divided 
muscular and fascial edges. We carry out this indication to such 
an extent that we have extended the line of denudation higher than 
Hegar does. The divergence between the separated fibres of the 




% 



; 



# 



Stoltz's Operation for Cystoeele and Hegar's Operation for Rectocele. 

levator ani and fascia is very apparent upon parting the labia in old 
cases, and these lines constitute the two depressed lateral angles. 
These two angles are near together at the vulval orifice, but diverge 
as they enter the vagina, until at the upper third they are not appa- 
rent at all. Between them is an elevation of greater or lesser promi- 
nence, which pouts out into the vulval orifice upon straining. This 
is the hernia of the rectum covered by the posterior vaginal wall. 
There are two parts of Hegar's operation — that which narrows the 
vagina, and that which approximates the muscular fibres and fascia. 
The former 'is entirely intra-vaginal, the latter partly vaginal and 
partly perineal. The sutures for the former are all intra-vaginal; 
those for the latter are vaginal and perineal. 



DISTORTIONS AND 3IALP0SITI0NS. 341 

At a point corresponding to the former fourchette, and above the 
level of the " angles," the mucous membrane of the vulva is caught 
by forceps and nicked with scissors. The same is done on the oppo- 
site side. High up on the posterior vaginal wall, above the recto- 
cele curve, a similar mark is made. The latter is joined to the two 
former by a light linear touch of the scalpel. The vulva margin 
is caught in forceps, and from its lower circumference a strip of tis- 
sue is removed to a point on the opposite side at a level with the 
first. This maneuvre is repeated until the denudation is complete, 
each successive strip being shorter than the preceding. Denudation 
completed, all bleeding from arterial branches must be checked by 
ligature with very fine catgut. Unchecked hemorrhage will produce 
hematomata and interfere with union. 

When the tear has extended through the sphincter the procedure 
is identically the same ; only the denudation should extend down- 
ward, so as to uncover the edges of the sphincter. When the recto- 
vaginal wall is torn, again the denudation is made in a triangular 
form, the tear in the rectum running through the centre of the 
denudation. In such cases the apex of the denudation must be at 
least half an inch above the upper margin of the tear, even though 
it be next the cervix. If this amount of tissue is not taken, the 
perineal part may close nicely, but leave a recto-vaginal fistula, 




Suture Tied in Stoltz's Operation for Cystoeele. Ptit 
Operation for Eec 



In passing the sutures a Hagedorn needle and holder are best. The 
first sutures passed are those in the vagina. They are of catgut, but 
may be of silkworm-gut or silver wire if subjected to much tension. 



342 AN AMEBIC AN TEXT-BOOK OF GYNECOLOGY. 

They are entirely buried, and are passed from side to side, one finger 
in the rectum guiding the needle. The continuous suture is inad- 
visable, but interrupted sutures should be used. When the suturing 
has proceded so far as to bring the last stitch passed through the 
middle of the rectocele — i. e. about three-quarters of an inch from 
the base of the triangle — the needle is threaded with heavy silk- 
worm-gut. The lowest suture is passed first, the needle entirely 
buried. The caution is necessary not to enter the needle too far 
out on the skin, but it should be just at the edge. Four or five of 
these perineal sutures are passed, the last or uppermost one extend- 
ing on the rectocele, up to the track of the last catgut suture, 
but not interlocking with it. 

When the fibres of the sphincter ani are torn, the lower margin 
of the denudation should extend above a quarter of an inch on each 
side, below the lines of junction of the anal mucous membrane and 
the cicatricial tissue. In these cases there is always more or less 
rolling out of the sphincter ends, and these lines may be readily 




Profile View of Hegar's Operation of Perineorrhaphy. 

discerned. In such cases the lower two sutures approximate the 
sphincter fibres. 

Where the recto-vaginal septum is torn a continuous suture 
should be passed from the rectum, from above downward to unite 
the lacerated borders. This converts the complete into an incom- 
plete laceration. When tied the knot of this suture is at the 
anal margin. All sutures being passed, the next step is to stretch 
the sphincter ani so as to paralyze it entirely. This is not done 
where the recto-vaginal wall or sphincter is torn. The suturing 
brings together fascia and muscle which perhaps for years have 
been separated and from disuse have atrophied. Hence such 
approximation is accomplished under great tension, which latter 



DISTORTIONS AND MALPOSITIONS. 343 

pulls against the sphincter ani, tending to separate its fibres. This 
muscle involuntarily contracts against the attempt, and produces a 
great deal of pain. In addition to this indication, stretching allows 
of the more free escape of intestinal gas. After the sutures are 
tied a stout drain of iodoform gauze is introduced into the vagina 
and projects from the vulva. The catgut sutures are tied in three 
knots, the silkworm-gut in two. Both should be cut to leave ends 
half an inch long. Iodoform is dusted on the perineum, and gauze 
placed over the sutures and held in place by borated cotton and a 
T-bandage. The vaginal gauze is removed at the end of forty- 
eight hours, and a vaginal douche of saturated solution of boracic 
acid given. Another drain is not introduced unless there be special 
indications for it, such as bleeding or sepsis. Twice a day the 
nurse should irrigate the perineal sutures with bichloride solu- 
tion, 1 : 4000. 

The patient should be given vegetable cathartic pills the second 
night, so as to operate on the third day. When she has the stool 
it may be softened by small enemata of saline solution. After this 
first stool others should be had every second day. The sutures are 
removed about the tenth day. If there be much tension, they may 
cut into the flesh. Alternate ones may be removed then on the 
seventh day. Scrupulous cleanliness is imperatively necessary 
throughout the whole after-treatment. The diet should consist 
largely of soups, vegetables, and fruits. Opium is not needed. 
There is no necessity for confining the legs after the patient has 
recovered her senses from the narcosis, and she may be allowed to 
lie on her side. Confinement to bed for at least two weeks is neces- 
sary, and longer if the operation be part of the procedure to correct 
prolapse. 

When the recto-vaginal wall has been torn and repaired, the 
after-treatment is somewhat different. As little disturbance as 
possible of the pelvic floor is here demanded. Therefore these 
patients should have received a most careful preparation as regards 
emptying the entire intestinal tract before the operation. After the 
operation they should receive liquid food only for three days, with 
cooked fruits. The bowels may gently be assisted by enema if they 
tend to move, but if not laxative pills may be given on the third 
night. In these cases, if the bowels are too fluid, particles are apt 
to leak into the wound, and if too hard, the stool may separate the 
united edges of the rectum. Rectal tubes, whether covered by 



344 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



gauze or not, are of no use, but rather harmful where there has 
been complete laceration. 

Flap-splitting Perineorrhaphy. — The objections to this opera- 
tion are twofold: It in no way narrows the vagina, and it only par- 
tially approximates the levator ani fibres. Its field of usefulness is 
very limited indeed. Practically, it is applicable to those cases in 
which only the superficial and most exterior fibres of the perineum 
are torn. That by means of it the separated sphincter fibres can be 
united is undoubtedly true. But where a tear is so extensive as to 
produce rectocele prolapsus the levator ani also is entirely separated. 
To unite the sphincter by flap-splitting is but part of the work indi- 
cated. In no way possible can this operation narrow the vagina, 
abolish a rectocele, or bring together the separated fibres of the pel- 
vic fascia, It should be performed only in the case of a patulous 



Fig. 218. 




l<"liip-s!>litliiiK lor Incomplete Laceration of the 1 



Relaxation ol the Vaginal Outlet. 



vulval orifice without rectocele, in the case of either complete or 
incomplete laceration of the perineum. 

The operation is performed with the patient in the dorsal posi- 
tion. The instruments required are a sharp-pointed pair of scis- 
sors bent on the flat, a handled perineum needle, and a tenaculum. 
Occasionally a pair of hemostatic forceps will be necessary to tem- 
porarily control bleeding. 

Foil Incomplete Lacekation. — The index finger of the left hand 



DISTORTIONS AND MALPOSITIONS. 



345 



being introduced into the rectum as a guide, the point of one of the 
blades of the scissors is thrust into the recto-vaginal septum, mid- 
way between the vaginal opening and the anus, to the depth of half 
an inch or more, care being taken that the instrument enters neither 
the vagina nor rectum. From this point the incision is made, first 
to one side and then to the other. The line of the incision is car- 
ried on each side outward and upward along the boundary-line 
between the vaginal mucous membrane and the skin of the labium. 
It is extended up the labium to that point at which it is desired the 
new vaginal floor shall exist; this point is usually that at which 
the lower caruncle (remnant of the hymen) exists, which point, in 
addition, can be located by the existent scar-tissue. The depth of 
the incisions tapers gradually until they reach the highest point 

Fig. 219. 




Flap-splitting for Complete Laceration of the Perineum : Laceration through the Sphincter Ani Muscle. 

on the labia. When completed the incisions form the elliptical 
figure U. 

For Complete Laceration. — Where the sphincter ani muscle 
is involved in the laceration the method of repair is precisely simi- 
lar, with the addition of two small slits. They are made by cutting- 
down each side of the anus to the ends of the retracted sphincter 
muscle, beginning the cuts at the curve of the original incision. 
Their length and depth are variable, depending upon the position 
of the retracted ends of the sphincter muscle, which must be exposed, 



346 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



so that when they are brought together the two ends may unite. 
When completed the incisions present the appearance as shown in 
Fig. 219. 

With the sides of the wound well separated the sutures are passed 
transversely. Beginning at the middle of the opening, the handled 
needle is made to pierce the skin about one-eighth of an inch from 
its cut edge, is carried three-quarters of the way to the bottom of 




Introduction of Sutures in Flap-splitting Operation. 

the wound, where it is made to emerge, and, being reintroduced at a 
point directly opposite the point of emergence, is carried under the 
tissues of the opposite side until it appears on the skin surface at a 
point directly opposite that at which it was first introduced. The 
eye of the needle is now threaded with a silkworm-gut suture and 
the needle withdrawn, dragging with it the end of the suture. Sev- 
eral similar sutures are passed above and below this median one. 
The topmost suture must pass through the vaginal flap as it is held 
11 [> by a tenaculum ; the lower suture, if the laceration be a complete 
one, must include both ends of the retracted sphincter muscle. The 



DISTORTIONS AND MALPOSITIONS. 347 

corresponding ends of the suture being now tied, or, better, shotted, 
the pelvic floor is lifted up toward the pubis by the crowding in 
below of the gluteal tissues. The result forms a fair support to the 
vaginal outlet, but in no way has any influence on any injury done 
to the vaginal floor. 

Inversion of the Uterus. 

This fortunately rare complaint is most often a complication of 
labor, and at times is fatal. But cases often live, and, as the con- 
dition results also from neoplasms, such as fibroids, they come to 
gynecologists as cases of chronic inversion. As such they will be 
described. 

That inversion may occur in the virgin uterus is undoubtedly true, 
but the vast majority of cases result from childbearing. It is neces- 
sary that the cervix be large and patulous, the fundus heavy and 
soft to enable the uterus to turn inside out, for such is, in reality, 
the condition in inversion. Continuous severe hemorrhage marks 
most cases. The patients are anemic, suffer great pain and bearing- 
down in the uterus, and frequently there is a profuse leucorrheal 
discharge, often purulent. They are very generally incapacitated 
for their work, and as time progresses they become more and more 
disabled by exhaustion. Examination shows a tumor symmetrical, 
firm, and of reddish color, filling the whole or part of the vagina 
as the inversion is partial or complete. Occasionally a fibroid 
polyp of greater or lesser size is attached to the inverted fundus, and 
this has probably been the exciting cause of the displacement. At 
first, in the early stages, the cervix is open and is occupied by a 
loop of intestine, but later it becomes contracted and merely con- 
tains the Fallopian tubes. The condition may also be associated 
with prolapsus, in which case the tumor may protrude from the 
vagina, under which circumstances it is not infrequently mistaken 
for prolapsus uteri. Generally the tumor is retained in the vagina. 
Inversion having taken place, the cervix contracts, and strangula- 
tion and gangrene of the uterus may result. Cases have been re- 
ported of spontaneous cure by the fundus sloughing away in con- 
sequence of the constriction to its circulation caused by the cervix 
squeezing it tightly ; also by the organ returning to its normal con- 
dition. Atlee reports an interesting case of this kind, where the 
inverted uterus was reduced by persistent and long-continued efforts 
at coition on the part of the husband after all other treatment had 



348 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

failed. The woman became pregnant and was delivered of a 
healthy child. The uterus had been inverted for years. Cases 
progress to a fatal issue from shock, due to hemorrhage, and pro- 
gressive asthenia, sepsis, or peritonitis. The usual cause of death 
in the chronic cases is exhaustion from the continuous loss of 
blood. 

The diagnosis must be made by examination, and is occasion- 

Fig. 221. 

, '. .-,,- .■■;•'■ , '• "■' ' " " ' '.'^.'tjfe',,^, •.■; "'«- 

i->- . .'• ■" ," ■';. '»., . ,:■ ■*-. -'' ■ 'V . ■-:'•:, .;,h i \fi\ 







litems : a, mons ven< 


ris ; /), the larger labia ; 


c, c, nymphse; d, elite 


vis- f 


meatus 


nterior border <if the 






^urfiiei 


of the 


outside. 











ally very difficult, although usually the condition is readily deter- 
mined by a vaginal exploration. The soft, uniformly-enlarged 
mass is felt filling the vagina, the upper end or pedicle of which is 
constricted by a ring of tissue, through which it is very evident 
that the mass protrudes. If that condition be made out satisfac- 
torily, the true lesion can hardly be overlooked. Should there 



DISTORTIONS AND MALPOSITIONS. 



349 



be any uncertainty as to the diagnosis, the bladder and rectum 
should be emptied. Examination combined by means of a sound 
in the bladder and a finger in the rectum will demonstrate the 
absence of the body of the uterus from its normal position, and 
the dimple of the inverted cervix will be felt from above. The 
tumor itself is firm, smooth, and the surface bleeds easily. The 
invariable diagnostic signs are the opening of the cervix above, 
which can be reached by the rectum, even though it may not be 
felt through the abdominal wall, and the very small openings of 
the tubes, at the sides of the base of this tumor, together with the 



Fig. 222. 




Complete Inversion: v, vagina; u c, incised uterus, showing the cavity; 6, border of the inverted por- 
tion ; the round ligaments, the Fallopian tubes, and the ovarian ligaments are drawn in ; I r, round 
ligaments ; t, Fallopian tubes ; o, o, ovaries ; h, cervix covered by peritoneum. 



constricting band of cervix, beyond which the finger cannot pass 
at any point about the pedicle of the tumor as felt in the vagina. 

The prognosis is unfavorable, on account of the constant loss of 
blood, it being only a question of time as to how long the patient 
can stand the drain. 

Treatment. — Chronic inversion is exceedingly difficult to cure. 
Gentle, continuous taxis, at the same time using some force, is the 
preferable method first to be tried. It is made as follows: The 
hand in the vagina grasps the fundus and exercises firm pressure 
upon it. The hand above, on the abdomen, attempts to distend the 



350 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

cervix and make counter-pressure, while the fundus is squeezed and 
pushed up. Many failures should not discourage the surgeon, but 
the pressure should be gradual and steady, care being taken not to 
use undue force, as must be the case in all efforts to overcome the 
contraction of unstriped muscular fibre. Peritonitis and death 
have been known to result from rough and too prolonged efforts 
in this direction. If the cervix yields, it yields rather suddenly. 
The attachments of the vagina to the cervix are of aid to the 
manipulations, and the tumor can be so pushed up as to render 
the vagina tense during the maneuvre. The operation is best 
performed with the woman under the influence of an anesthetic. 
Repeated failures after conscientious effort compel us to consider 
continuous elastic pressure, removal of the organ, or, possibly, 
attempt at replacement by Thomas's method. 

Taxis having failed, continuous elastic pressure must be tried. 
The bladder and bowels being empty, the uterus is pushed up if 
prolapsed, and a Braun's colpeurynter, previously soaked in a sat- 
urated solution of boracic acid for several hours, is introduced. 
This is then injected with tepid water until it fills the pelvis very 
snugly. 

The contents of the colpeurynter are to be gradually increased. 
It should not be left in too long, but once a day should be removed 
for a few hours, the parts and the colpeurynter cleansed, and the 
latter reintroduced. Few cases will resist this method of treatment. 
The object of the treatment is to exercise a continuous pressure, not 
sufficient, however, to obstruct circulation to too great an extent. 
During the treatment the patient should be kept in bed ; indeed, 
the pain produced by the colpeurynter is pretty severe, and would 
of itself confine the woman to bed. Morphia for its relief is indi- 
cated, but should not be pushed too far. 

The only caution to be made is that the physician should not 
become too easily discouraged in his attempts to replace by taxis 
and the colpeurynter. 

It is now twenty-three years since Thomas advocated opening the 
abdomen and dilating the cervix, and in that time the mortality from 
celiotomy has fallen to a very small percentage ; therefore when taxis 
and the colpeurynter have been given repeated tests and have failed, 
Thomas's operation may be tried, although without much prospect 
of success. If replacement cannot be made by Thomas's method 



DISTORTIONS AND MALPOSITIONS. 351 

very promptly, at the same sitting the organ can be removed by 
abdominal hysterectomy in a few minutes. 

Thomas's Operation for Inversion. — Thomas succeeded with one 
case, and lost his second from infection — something which now may 
be prevented. Other successful cases have been reported. A con- 
sideration of the technique of the operation and the changes in the 
uterus gives promise that the mortality can be kept below 10 per 
cent., but the proportion of successes is very slight. 

The patient is prepared for both a vaginal operation and a 
celiotomy. The special instrument required is Thomas's dilator. 
It might be modified usefully by making the flanges wider, so that 
at the act of dilating pressure upward may be made, thus con- 
tributing to the rolling out of the inversion. The dilating portion 
need not be so long. A short abdominal incision only is necessary, 
merely sufficient to ascertain the condition of the intraperitoneal 
tissues. The abdomen being open, the operator's left hand is intro- 
duced into the vagina and the mass pushed up to the incision. The 
dilator is introduced and the upper part of the constriction dilated 
at the same time. This is an important observation by Thomas — 




Thomas's Operation for Replacement of the Inverted Uterus. 

that the reduction takes place in a manner exactly the reverse of 
that in which the inversion occurred. In this way each fraction of 
the constriction is successively dilated, and the inversion is reduced 
in stages beginning with the cervix. The caution is necessary to 
so apply the instrument as not to wound the tubes. Because of the 



352 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

possibilit} r of this it might be better to try the fingers arranged into 
a cone before using the dilator. 

Vaginal amputation of the corpus uteri is at no time justifiable. 
If conservative methods fail to reduce the deformity, the uterus must 
be removed in toto. Should the abdomen be opened for a trial with 
Thomas's operation, and that fails, as has usually been the case, re- 
moval of the wound through the abdominal opening is the proper pro- 
cedure. Should it be decided from the first not to try the Thomas 
method, but to remove the displaced organ, vaginal hysterectomy is 
the proper procedure to be adopted. 

To recapitulate, gentle but well-directed efforts at taxis are to be 
first tried, with the patient under an anesthetic. Should this not 
accomplish the object at a single sitting of an hour, or show very 
decided signs of ultimate success, continuous elastic pressure by 
means of the colpeurynter or Aveling's repositor is to be tried. 
Should this give no promise of success after several days' trial, 
vaginal hysterectomy is the most rational procedure. 



MALIGNANT DISEASES OF THE FEMALE GENITALIA. 



The term " malignant " is applied to those affections of the 
female genital organs which progress toward a fatal termination and 
have a tendency to return after removal. They are attended with 
a characteristic rapid involvement of the surrounding tissues and a 
marked general infection, as is evidenced by cachexia, debility, and 
the metastatic involvement of the internal organs. 

At first these diseases are local, and if early recognition be fol- 
lowed by immediate removal, a perfect cure may in many cases be 
expected. After attaining a considerable size and involving the 
inguinal or post-peritoneal lymphatic glands their removal is simply 
palliative. 

The malignant diseases to which the female organs of generation 
are subject are, in the order of their frequency, carcinoma, epithe- 
lioma, and sarcoma. Occasionally a mixture of carcinoma with 
sarcoma is observed. 

Malignant Diseases of the Exteknal Genitals. 

Carcinomatous tumors are frequently observed in women in the 
organs of generation, but malignant tumors of the external genitals 
are more rarely met with. 

The forms of malignant tumors of the external genitals, in the 
order of their frequency, are, epithelioma, carcinoma, and sar- 
coma. 

Epithelioma develops usually on the lower part of the inner sur- 
face of the greater labium in the form of small, round, hard nodules 
which project above the level of the mucous membrane and have a 
rough, uneven surface. They are usually of a whitish color, and 
may remain for a long time unnoticed. They grow slowlv in their 
incipiency and are painless. Sooner or later the vascular supply to 
the tissues is increased, and the growth becomes more rapid, the 

23 353 



354 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

superficial epithelial layer is lost, ulceration begins and spreads to 
the surrounding tissues, and the original seat of disease progress- 
ively increases in area. The rounded form of the original nodule 
is preserved for a long time by the even extension of the induration. 
The ulcers are surrounded by hard, raised margins of a bluish-red 
color, covered with rough granulations, and bathed in a purulent 
ichorous secretion with unpleasant odor. The ulcers, later in the 
course of the disease, may become the seat of papillary excrescences 
which at times attain a large size. 

As soon as the purulent sore is formed the induration spreads 
more rapidly, and usually in the direction of the long axis of the 
greater labium, and upon its inner surface. It is exceptional for it 
to extend beyond the myrtiform caruncles or to the abdominal wall. 

In the course of its growth the epithelial cancer usually first 
involves the lesser labium, then the prepuce of the clitoris and the 
clitoris itself. These parts redden, become swollen and indurated, 
and then ulcerate, forming a long indurated ulcer of a dirty-red 
color, with irregular edges, extending from the lower part of the 
greater labium to the mons Veneris. It is rare for the disease to 
spread to the labium of the opposite side. 

The inguinal glands do not become infiltrated until the ulcerated 
sore has existed for a long time. When this occurs the disease 
rapidly attacks the deeper tissues which up to this time have not 
shared in the involvement. The entire labium assumes a dark- 
red color and becomes swollen, hard, and painful. The epithelial 
sore advances to the perineum and the thigh, forming a deep ulcer 
with an irregular surface. One or more of the inguinal glands may 
harden, take on a rapid growth, ulcerate through the skin, and 
form a sore extending deeply into the tissues. 

The etiology of epithelioma is but little known. It occurs only 
in the later years of life, and most frequently about the time of the 
menopause. Heredity appears to have no influence in its occurrence. 
While it usually has its seat on one side of the vulva, it has been 
observed primarily on both labia. Blows and falls upon the labia 
have been referred to as causes, but it is difficult to decide what causal 
relations, if any, they hold to the disease. The pruritus which 
always accompanies epithelioma of the vulva, and is most violent 
in the beginning, has been by some authorities considered not a 
symptom of that disease ; they contend that the epithelioma is a 
result of the continuous rubbing and scratching of the parts for the 



MALIGNANT DISEASES OF THE FEMALE GENITALIA. 355 

relief of the pruritus. This theory, however, has gained few con- 
verts, and is most probably not the correct one. 

Epitheliomatous nodules may exist for months without produ- 
cing symptoms other than obstinate pruritus, or materially chang- 
ing their form or size. As soon as ulceration begins the process 
becomes rapid, and usually causes death in two ^ears. There is 
persistent pain, which is not so severe as in other forms of can- 
cer. The patients suffer from insomnia, are wasted, and gradually 
acquire an earthy complexion. The appetite is almost completely 
lost. The secretions from the ulcerated surfaces are not so copious 
or so offensive as those from cancer. Hemorrhages may occur, but 
are not common. The loss of flesh and strength progresses rapidly, 
and the patients die, usually in about two years, from chronic sep- 
tic infection. 

The treatment of epithelioma of the vulva consists in its early 
excision, including enough healthy surrounding tissue to ensure its 
complete removal. The use of caustics, at any stage of the dis- 
ease, for the removal of the growths, cannot too emphatically be 
denouuced as unscientific and untrustworthy, increasing the suffer- 
ings of the patients and giving them no assurance of complete 
removal. The use of caustics is nearly always followed by a quick 
return of the disease, whereas if the growth be early and freely 
excised, before there is involvement of the inguinal lymphatics, 
the chances for a perfect cure are, in some cases, fair. Even where 
glandular enlargement of the inguinal lymphatics is present, excis- 
ion of the growth and removal of the chain of glands will most 
probably prolong the life and will certainly relieve the sufferings 
of the patient. If the infiltration has spread over the perineum 
and on to the thighs, or if the inguinal lymphatics have ulcerated, 
the treatment should be, naturally, palliative. For these advanced 
cases the use of compresses wet with a saturated solution of chlorate 
of potash has been recommended. 

Scirrhous carcinoma, sarcoma, and medullary sarcoma of the vulva 
as primary growths are extremely rare. The point of origin of 
these tumors is usually the greater labium. Scirrhous carcinoma 
has been observed in the clitoris and in the tissues adjoining the 
clitoris. Sarcomatous growths may originate in the nymphse. Me- 
dullary sarcoma has been observed to grow from urethral caruncle. 

The growth usually develops as a deeply-seated nodule, which 
rapidly spreads toward the skin surface. The overlying skin be- 



356 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

comes adherent and ulcerates, forming an irregular, uneven sore, 
secreting a copious purulent, ichorous discharge. It is a disease 
essentially of old age, occurring usually between the sixtieth and 
seventieth years. 

The symptoms are much more violent than those of epithe- 
lioma. In the early stages there are pruritus, increased vaginal 
secretion, and the mechanical inconveniences of the tumor according 
to its situation. The pricking, tearing carcinomatous pains occur 
early. The purulent ichorous discharges are profuse. Copious, 
weakening hemorrhages frequently occur. The inguinal lymphat- 
ics are early involved. The patients, as a rule, rapidly decline in 
health, and soon die through progressive loss of strength and meta- 
stasis to the internal organs. 

If the case is seen before extensive involvement of the inguinal 
lymphatics has taken place, the growth should be excised freely 
with the knife or removed with the Paquelin cautery. The opera- 
tor should remove all doubtful parts, without fear of a too great 
loss of tissue. Unfortunately, most of these cases come under the 
gynecologist's notice when wide extension of the growth and the 
involvement of the lymphatics render the treatment only palliative 
and symptomatic. These cases then require the use of antiseptic and 
disinfectant washes to correct the fetor of the discharges, alum and 
Monsel's solution to control the hemorrhages, and the plentiful use 
of opium to render the patients' last days as comfortable as possible. 

Carcinoma of the urethra is a very rare disease, and usually sec- 
ondary to cancer of the external genitals or vagina. Carcinoma, 
of the bladder rarely involves the urethra. 

The treatment consists in excision. If removal of the mass is 
not possible, the urethral canal should be kept open by the daily 
passage of the catheter. Should the growth become too extensive 
for this, an artificial vesico- vaginal fistula should be made to provide 
for the escape of the urine. Local cleanliness and anodynes for the 
relief of the pain are mainly to be relied upon when the disease has 
progressed too far for surgical relief. 

Periurethral cancer develops in the form of nodules in the vesti- 
bule of the vulva near the urethral orifice, or in the cellular tissue 
along the sides of the urethra without involving its walls. The 
mouth of the urethra is usually secondarily involved. The nodules 
are at first hard, non-ulcerated, painful upon pressure, and occasion- 
ally the seat of lancinating pain. The pain usually first causes 



MALIGXAXT DISEASES OF THE FEMALE GENITALIA. 357 

their discovery. At times they are not observed until ulceration 
has occurred and hemorrhage invites search for its cause. The 
nodules rapidly infiltrate the surrounding tissues, filling the whole 
vestibule, following the course of the urethra to the neck of the 
bladder and to the pelvic fascia, and finally extending over the 
symphysis and descending rami of the pubis, and involving all of 
the included tissue. 

The treatment is operative if early seen — palliative if there is 
extensive involvement. 

Malignant Disease of the Vagina. 

The vagina may be the seat of carcinoma, epithelioma, or sar- 
coma. The carcinomatous and epitheliomatous affections are usually 
secondary, while the sarcomatous are principally primary growths. 

Sarcom,a of the vagina appears either in the form of a circum- 
scribed rounded tumor growing from the submucous tissue or as a 
diffuse superficial degeneration of the vaginal wall. Tumors of the 
first variety may readily be confounded with fibro-myoma, and the 
second form may be mistaken for carcinoma. The growth may 
occur as a small warty tumor, or as a rounded or oval nodule which 
may reach the size of a goose-egg. The usual seat of sarcoma of 
the vagina is upon the posterior wall. The circumscribed sub- 
mucous sarcomata are usually composed of spindle-cells ; they 
ulcerate late in their course, and occasion symptoms analogous to 
those of the fibro-myomatous tumors of the vagina. There is pain, 
especially at night, obstruction of the vaginal canal, and hemorrhage 
after ulceration has taken place. 

The superficial sarcomatous degeneration of the vaginal wall 
occurs, usually upon the posterior wall as a small tumor, which 
slowly increases in size and resists treatment. Finally, it loses its 
mucous covering, and forms an ulcer with elevated edges and covered 
with readily bleeding granulations. Involvement of the inguinal 
glands does not take place until late in the disease. Hemorrhage 
is a prominent symptom, occurring after violent motion or excited 
by coitus or by straining at stool. The entire peripheiy of the 
vagina may finally become involved. 

The diagnosis cannot be made with certainty without micro- 
scopic examination of pieces of the growth. A strong presumption 
of the presence of the disease is not, however, difficult to estab- 
lish. 



358 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

The prognosis is more favorable in the circumscribed sarcomata 
than the diffuse, on account of the greater probability of their com- 
plete removal, although it is extremely bad in both. 

The treatment in the circumscribed form is operation if seen 
before ulceration and lymphatic involvement has occurred. 

In this, as well as in the diffuse form, the treatment is identical 
with that of carcinoma, if the disease has progressed beyond removal 
by the knife. 

Carcinoma and Epithelioma of the Vagina. — Secondarily, the 
vagina is frequently invaded by carcinoma and epithelioma ; it is 
rare, however, to find these growths occurring primarily. It may 
be involved by the extension of uterine carcinoma, of carcinoma 
of the rectum, vulva, urethra, least frequently of carcinoma of 
the bladder, and finally, as metastatic nodules following the re- 
moval of a primary cancer. The primary cancer of the vagina 
appears principally in two forms : papillary epithelioma, which is 
most frequent, or diffuse carcinomatous infiltration of the vaginal 
wall. 

The first form appears as a circumscribed sessile growth, most 
frequently situated upon the posterior wall. The second form is a 
carcinomatous infiltration of the vaginal wall, usually circular in 
outline, involving large areas of tissue and occupying the mucous 
membrane and submucous layer. It may be of either the medullary 
or scirrhous type. 

Concerning the etiology very little is known. The cases occur 
with greatest frequency between the ages of thirty-one and forty. 
Young individuals are seldom affected. Traumatic insults — such, 
for instance, as the pressure of badly-fitting pessaries — have been 
urged as causes. But this opinion is unquestionably erroneous. We 
lay stress upon this point, because among the laity, cancer even of 
the womb is so commonly attributed to the irritating pressure of 
pessaries, that the physician is often much hampered in their use by 
the fears of his patient. Primary cancer of the vagina is extremely 
rare. In a large experience but three cases of it have been seen by 
the author. In each case the sore was just behind the cervix, yet 
in not one had a pessary ever been used by the patient. Of course 
to cancer of the womb the pessary can bear no causal relation what- 
ever, because it does not come in contact with that organ at any 
point. 

In the course of carcinoma of the vagina, in all its forms, there 



MALIGNANT DISEASES OF THE FEMALE GENITALIA. 359 

is a rapid progress toward ulcerating degeneration of the tumor, 
while peripherally and upon its base the neighboring tissues are 
invaded. By the advancing destruction of the tumor the cancerous 
ulcer is formed which may readily perforate into the neighboring 
cavities. From the frequent seat of the neoplasm upon the poste- 
rior vaginal wall, recto-vaginal fistula is usually the first to form. 
The further extension in the lymph-channels involves, in sympathy, 
the lymph-glands in the pelvic connective tissue, and, if the growth 
is deeply seated, also the inguinal glands. 

The symptoms consist principally of hemorrhage, ichorous dis- 
charge, and pain. Occasionally the patient complains of the 
mechanical inconveniences of stenosis and of obstruction of the 
lumen of the vagina, as impediments to sexual intercourse, or the 
disease may first be recognized during labor as obstruction in the 
birth-canal. Lastly, those disturbances arising from the involve- 
ment of the neighboring organs, the rectum and the bladder, may 
be the first clue to the disease. 

The essential and never-failing symptoms are the anomalies of 
secretion — hemorrhage and the watery and ichorous discharge. 
These depend for their prominence upon the form and vasculariza- 
tion of the carcinoma and the stage in which it comes under obser- 
vation. The hemorrhage usually first makes its appearance after 
coitus or after the straining at stool. Death occurs usually after 
spreading of the ulceration from the progressive debility caused by 
the hemorrhages and discharges. It may also occur in very vas- 
cular growths from hemorrhage. Pregnancy may occur in the course 
of vaginal carcinoma, and the growth then forms a serious compli- 
cation in labor. 

The requisites for the diagnosis of vaginal carcinoma are the 
presence of either a firm sessile tumor immovably fixed in the 
tissues, with an ulcerated surface, or an infiltrated ulcer. Serous 
or ichorous discharge is always present, and hemorrhage is easily 
produced by contact. Papillary epithelioma may appear as a cauli- 
flower growth, and is to be distinguished from unusually large 
benign papilloma by the greater tendency to hemorrhage and the 
striking brittleness of its tissue. From sarcoma the differential 
diagnosis is to be made only by the microscope. It is of import- 
ance to determine if the carcinomatous growth be of primary or 
secondary origin. A thorough investigation of the neighboring 
organs and the position of the growth will determine this question. 



360 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

The growth is only to be regarded as a primary vaginal carcinoma 
when rectum, vulva, bladder, and urethra are excluded as points 
of origin, and the portio vaginalis remains uninvolved or is 
attached only externally next to the vaginal growth, and no other 
distant organ is the seat of cancerous disease. The epithelial and 
papillary forms of cancer usually involve the vagina secondarily 
by extension of their growth from the neighboring organs by con- 
tinuity of tissue. Carcinoma developing from infiltrated nodules 
may occur in the vagina by metastasis from distant organs, as can- 
cer of the stomach. 

Unfortunately, in most cases of cancer of the vagina it is impos- 
sible to remove the entire growth. Destruction of the mass has 
been fruitlessly attempted with the sharp curette, the galvano- 
cautery snare, and cauterization with the most varied corrosives. 
Yet under certain circumstances one is forced to employ them. 
When the tumor is so far circumscribed that its total extirpation 
with enough surrounding healthy tissue to ensure its complete 
removal is possible, this is the only procedure. The operator 
should not hesitate from fear of too extensive a wound to remove 
all suspicious tissue. Should the inguinal chain of lymphatics be 
enlarged, they too should be removed. Owing to the elasticity of 
these tissues it is often possible after extensive removal of the 
vaginal substance to unite the edges of the wound by suture. 

Usually the cases come under notice too late for operation. The 
treatment is then palliative. The hemorrhage and discharge are 
best controlled by the destruction of the cancerous mass by the use 
of the curette, galvano-cautery, or corrosives. Great care must be 
exerted in applying these means that the bladder, rectum, or 
peritoneal cavity is not opened. Vaginal suppositories, contain- 
ing equal parts of pure pepsin and salicylic acid — say, from five to 
ten grains each — have been found useful. Sometimes the dry powder 
is applied directly to the ulcer, and confined there by a tampon of 
cotton. This application is very irritating to the vulva and out- 
lying genitalia, which should therefore be protected by a coat of 
vaseline or of zinc ointment. The hemorrhage may become very 
alarming, and require tamponing of the vagina with gauze wet in 
saturated alum solution or with absorbent cotton that has been 
wet with Monsel's solution and dried. Later in the disease the 
discharges will require suppositories of chloral and tannic acid, or 
douches of peroxide of hydrogen or permanganate of potash, to 



MALIGNANT DISEASES OF THE FEMALE GENITALIA. 361 

correct their odor. The pains imperatively demand the use of 
narcotics, and, as in all cases of advanced ca«ncer, these drugs 
should be given in increasing doses according to the effect upon 
the patient. There is no excuse for allowing these doomed women 
to suffer more pain than is necessary, and the physician is not 
doing his whole duty if he neglects to provide his patient with the 
comfort which opium gives. 

Saecoma of the Womb. 

Primary sarcoma of the uterus occurs anatomically and clinically 
in two forms — fibro-sarcoma, or sarcoma of the uterine parenchyma, 
and diffuse sarcoma, or sarcoma of the uterine mucous membrane. 
Both forms may consist of round or of spindle cells. 




Sarcoma of the Body of the Uterus. 



Fibro-sarcoma forms a more or less firm, occasionally soft, cir- 
cumscribed, rounded tumor growing from the uterine parenchyma 
and resembling the fibroid tumor. Like these growths it may be 
submucous, subserous, or interstitial. The growth occurs in the 



362 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

form of rounded nodules, of a rich cellular formation, which appear 
to have invaded the original tissue. When submucous or subserous, 
they form sessile tumors projecting into the cavity or upon the sur- 
face of the uterus. As interstitial growths they are imbedded in 
the tissues of the uterus and form thickenings of its wall. The 
isolated sarcomatous tumors are usually composed of round cells. 
The spindle-celled fibro-sarcoma usually occurs in disseminated 
nodules lying in the uterine parenchyma, but it may infiltrate 
equally the whole organ. It is rare for this growth to appear upon 
the cervix. Often the uterine fibro -sarcomata are the result of 
sarcomatous degeneration of fibro-myxomatous tumors. 

The diffuse sarcomatous tumors grow from the connective tissue 
of the uterine mucous membrane, and are mostly composed of 
small round cells, seldom of spindle cells. They appear as very 
soft knotty or papillary growths upon the mucous membrane. 
They may occur in single areas or infiltrate the whole mucous- 
membrane. The growth usually involves the uterine wall, which 
it penetrates, forming a tumor upon the peritoneal surface. Those 
intestines lying near become involved, adhesions are formed to the 
abdominal wall, and the neighboring organs are invaded by the 
disease. The soft round-celled medullary sarcomata may present 
themselves as polypoid growths attached to folds of the mucous 
membrane. They are grayish-white in color, resembling brain- 
matter, rich in blood-supply, and of soft consistency. The surface 
is usually necrotic, uneven, and dotted over with fungus-like masses. 
The necrotic surfaces are covered with dark-brown colored sloughs. 
These growths are closely related to the cancerous degenerations of 
the uterine mucous membrane. The cervical mucous membrane 
seldom appears to be the point of origin of the diffuse sarcoma. 

Concerning the causes of the origin of sarcoma little is known. 
It may occur at any age. We have observed it as early as the 
twentieth year and as late as the seventieth. But undoubtedly 
there is a special predisposition for the development of sarcoma 
at the climacteric period. There is no reliable proof, as is often 
asserted, that fibro-myomata undergo change into sarcoma. It is a 
disease which especially attacks nulliparae. It has been remarked 
that diffuse sarcoma originates in the interglandular connective 
tissue of the mucous membrane, just as carcinoma of the body of 
the uterus develops from proliferation of the cells in the glandular 
element. 



MALIGNANT DISEASES OF THE FEMALE GENITALIA. 363 

As the symptoms of the two forms of sarcoma differ essentially 
in character, they will be described separately. 

The most prominent symptoms occasioned by the fibro-sarcomata 
are those caused by pressure according to the position and the size 
of the tumor. Pain resembling in character labor-pains, hem- 
orrhages, and watery discharge are the cardinal symptoms. The 
pain may wholly be absent or be slight. It is occasioned by 
the attempts on the part of the womb to expel the mass, and is 
referred to the dorsal and hypogastric regions. Hemorrhage is 
first recognized as profuse menstruation, and does not change its 
character until a late stage of the disease. The discharge may be 
exceedingly profuse, of a bloody, serous, or watery character, and 
finally with a very unpleasant odor. 

The uterus is much increased in size and the cervical canal is 
tense. The cervical canal may, however, be dilated and patulous, 
permitting the introduction of the finger. The tumor-masses may 
project from the os into the vagina, or with a patulous cervical 
canal the finger may recognize the soft growths in the uterine 
cavity. The tumor may be expelled into the vagina by uterine 
contractions, which may indeed invert the womb. Pieces of the 
mass can readily be broken off by the examining finger before 
sloughing has taken place. 

There is a marked cachexia and rapid loss of flesh and strength, 
and finally death from peritonitis; pyemia, ileus, or metastasis takes 
place, ushered in by extreme anemia. The metastasis is more fre- 
quent in fibro-sarcoma than in the diffuse form, and occurs in the 
lymphatic glands, the lungs, the liver, and the pelvic cellular 
tissue. 

In the diffuse sarcomata there is usually no distinct tumor to be 
recognized externally. The womb is enlarged and fixed. The 
growth may push itself through the os, giving the picture of a 
circumscribed tumor. This projection through the cervical canal 
is not due to expulsive efforts on the part of the womb, as in the 
fibro-sarcoma, and is not attended with labor-like pains, but is due 
to the rapid development of the neoplasm. Pieces of the mass 
readily break off, and are carried away by the discharges. Hem- 
orrhage is seldom absent, and is usually violent. The menstrual 
type is soon lost, and as the disease usually occurs in the climacteric 
period or later, the hemorrhages excite alarm. The hemorrhage 
may be replaced - , especially in the beginning of the disease, by 



364 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

a continuous slight bloody discharge. Along with these profuse 
losses of blood is a rich watery or bloody-serous discharge, that 
is present before sloughing of the tumor-mass has taken place, 
and is usually of a disagreeable odor. Sloughing occurs early, 
and with it the discharge takes upon itself the peculiarities of 
the secretion from the gangrenous parts. The pain, very sel- 
dom absent, is often of great violence. It is of a tearing charac- 
ter, and depends for its intensity upon the depth to which the 
sarcomatous infiltration has penetrated. Death occurs, preceded 
by rapid debility and extension of the growth through the uterine 
walls to the neighboring organs and pelvic floor. 

The certain diagnosis of sarcoma of the womb is arrived at only 
by the careful microscopical examination of its structure. The 
examination of small particles contained in the discharges is not 
sufficient to establish an absolute diagnosis. Either pieces of the 
extirpated growth or portions of the tissue removed deeply from 
the tumor by means of the sharp curette should be used. The 
presence of sarcoma must be suspected when a supposedly fibrous 
tumor is discovered in the climacteric period, or when a small sup- 
posedly fibrous tumor, formerly occasioning no symptoms, at this 
time or later begins to increase in size or to be attended with pain 
and hemorrhage. The occurrence of hemorrhage in supposed fi- 
broma of the uterus, when menstruation has for a long time ceased, 
should always excite grave suspicion. The hemorrhage in fibrom- 
yomata ceases or lessens when the climacteric is passed. The 
copious bloody-serous discharge is a still more characteristic symp- 
tom, which, while not always present in fibro-sarcoma, never accom- 
panies benign fibrous tumors except when sloughing has occurred. 
A further characteristic symptom of sarcoma is the abnormally rapid 
growth, especially if observed in the climacteric years, when fibrom- 
ata do not usually increase in size. This is convincing when the 
growth is soft and accompanied by unusually violent pain. The 
softness of the growth on palpation, permitting the ready penetra- 
tion of the finger into the tumor-mass, is, when sloughing fibroid is 
excluded, decisive for the diagnosis of sarcoma. 

When to these symptoms are added an unproportionate loss of 
flesh and strength, cachexia, and anemia, the diagnosis is made with 
ease. The exact diagnosis should always be made after extirpation 
by microscopical examination. 

The differentia] diagnosis between diffuse sarcoma and carcinoma 



MALIGNANT DISEASES OF THE FEMALE GENITALIA. 365 

of the fundus is never easy and may be impossible. From carci- 
noma of the vaginal portion of the womb sarcoma may easily be 
recognized. In the latter disease the sarcomatous mass will be 
found projecting into the vagina through a healthy cervix, the 
margin of the os being recognized by the finger as a constricting 
band. 

Much more difficult is the recognition of diffuse sarcoma from 
certain benign hypertrophies of the uterine mucous membrane, as 
endometritis fungosa. This affection seldom occurs after the climac- 
teric, as is the case with diffuse sarcoma ; the age of the patient is 
therefore of some help in establishing the differential diagnosis. 
The general condition of the patient is of great importance. In 
fungoid endometritis the patient may be anemic, but never becomes 
cachectic. The bloody-serous discharge is seldom present. The os 
is more or less patulous in diffuse sarcoma, admitting the finger. 
It is closed in endometritis. In sarcoma the uterus is large, and 
tender to pressure; in endometritis the size is not increased and 
there is no tenderness. The rapidly-proliferating sarcomatous 
growth frequently projects from the os, polyp-like, into the vagina; 
this never occurs in benign hyperplasias of the uterine mucosa. 
The benign hyperplasias always remain superficial growths, never 
involving the uterine substance. Sarcomatous growths belong 
usually to the deeper layers from the beginning, and infiltrate 
rapidly the uterine substance. The polypoid growths of fungoid 
endometritis sometimes grow again after removal, yet the return 
growths differ wholly from the residual growths of sarcoma. 

The microscopical examination of the pieces found in the dis- 
charges often leads to error, as in sarcoma they may long consist 
of healthy tissue, and in simple hypertrophy, of granulation tissue 
resembling small round-cell sarcoma. Errors may be avoided by 
examining several pieces of the growth removed from different 
positions. It is safe to always assume that endometritis fungosa, 
so called, is in reality an early stage of beginning malignancy. 
Many patients have been allowed to progress so far as to be incur- 
able under the supposition that the disease was benign. There is 
grave doubt whether such a thing as benign endometritis fungosa 
exists. 

The prognosis in both forms of sarcoma is hopeless when a 
whole growth cannot be removed by ojDerative measures. These 
growths may progress, slowly or quickly, to death. Compared with 



366 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



the carcinomata, the prognosis for cure by complete removal is more 
favorable, as the lymphatic involvement is slower and the early 
recognition more probable. 

The treatment consists in total hysterectomy when the disease 
is recognized before involvement of the broad ligaments or of neigh- 
boring tissues has rendered the operation impracticable. Only when 
the removal is no longer possible should the treatment be symptom- 
atic. In the abandoned cases the symptoms may be for a time 
controlled and the life of the patient prolonged by scraping away 
the diseased tissue with a sharp spoon and cauterizing the surface 
of the wound. The cauterization may be performed by the use of 
chromic-acid solution, fuming nitric acid, chloride-of-zinc solution, 




Epithelioma of the Cervix Uteri, showing the well-defined limitation of the disease. 



or, better, by the Paquelin thermo-cautery or by the galvano-cau- 
tery porcelain burner heated to a red heat. The further treatment 
is analogous to that of carcinoma — tonics and attention to the bowels, 
whilst opium must be given to relieve pain. 



Cancer of the Cervix. 

Of all women who die from cancer, one-third die from cancer 
of the uterus. The disease is not so common in the negress as in 
her white sister. Uterine cancer occurs most frequently between 



MALIGNANT DISEASES OF THE FEMALE GENITALIA. 367 

the ages of thirty and forty years and between fifty and sixty 
years. It has not been observed under seventeen years, one case 
being reported in a girl of that age. The frequency of its occur- 
rence increases from thirty years to the menopause, after which it 
again decreases. Very many cases, however, have been observed 
after the climacteric period. 

Only a small percentage of patients suffering from uterine cancer 
are nulliparae. Deep laceration of the cervix with ectropion of the 
lips, if unheeded, is a possible predisposing cause of cervical cancer. 
It would appear that the constant irritation to which the raw, gran- 
ular everted lips are subjected in locomotion and coition is the dan- 
gerous element. Long-standing cervical catarrh has also, perhaps, 
a causative influence. Finally, the cervix uteri, like most other ostia, 
as the lip, the pylorus, the cecum, and the rectum, is a favorite seat 
for cancer. 

Heredity exerts a considerable influence in its causation. Among 
the higher classes of society carcinoma relatively seldom occurs, 
while among those of the lower grades, who are required to strug- 
gle for the necessities of life, cancer is observed with striking fre- 
quency. In this respect the occurrence of cancer is directly in 
contrast with that of uterine myoma. 

Epithelioma of the cervical mucous membrane may grow from the 
squamous epithelium of the rete Malpighii, from the cylinder epi- 
thelium within the cervix, or from the glandular epithelial cells. 
Cancer of the uterine parenchyma has its origin in connective- 
tissue cells. 

Cancer of the cervix may present itself either as a papillary or 
cauliflower growth, a nodular or parenchymatous growth, or a super- 
ficial or ulcerating disease of the mucous membrane. 

The cauliflower or papillary form grows from the intravaginal 
portion of the cervix, and may be limited to it for a long time. It 
may develop so profusely as to hide the remaining healthy portion 
of the cervix and the os, appearing as a large papillary growth 
filling up the upper portion of the vagina. Finally, the growth 
spreads to the vaginal vault, which it deeply involves, all the tissues 
surrounding the uterus sharing in the infiltration. Extension may 
take place through the cervical canal to the endometrium by con- 
tinuity of tissue, and the body of the womb may become involved. 

The nodular or parenchymatous form of cervical cancer has its 
origin in one or more nodular formations in the cervical mucous 



368 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

membrane. Usually they are situated just beneath the membrane, 
although they may be upon its surface. The nodules soon part 
with their covering of mucous membrane, and form ulcers which 
fuse together and, by extension, involve the fundus of the uterus 
and the vaginal cul-de-sac. The bladder, rectum, and pelvic 
cellular tissues may finally become invaded. 

The superficial or ulcerative form begins as an infiltration of the 
mucous membrane of the cervix. The infiltrated area soon parts 
with its covering of mucous membrane and ulcerates. The ulcer 
progressively involves the deeper tissues, losing its necrotic surface 
as it advances, until finally the whole womb may be converted into 
a crater-like cancerous mass. By extension the peri-uterine tissues 
are invaded, while the vagina may be involved but little. 

To the malignancy of the cervical carcinoma is added increased 
danger from the fact that the beginning, as a rule, is attended by no 
symptoms, and the disease is almost always discovered when it is 
too late for radical treatment. Only in the superficial or ulcerative 
form of cancer is the early stage attended with discharge and occa- 
sional hemorrhages. The other forms of cancer are attended with 
very slight discharge, and, other symptoms being absent, the case 
does not come to seek the advice of the gynecologist until the can- 
cerous sore has already formed. This is attended with a more 
copious discharge and bleeding, which may occur periodically and 
be confounded with metrorrhagia from other causes. If the patient 
has not passed the menopause, the hemorrhages begin as increase 
in the normal menstruation, but later on occur between the periods. 
Frequently the first symptom noticed is hemorrhage following coitus. 
In the scirrhous form of the disease the bleeding may be absent, yet 
it very generally accompanies the disease, and it may be very alarm- 
ing. The most extreme grade of anemia may result from the repeated 
hemorrhages, yet they very rarely are so copious as to produce death. 

The first hemorrhage is usually followed by a sanious discharge, 
which may be slight and attract no more attention than the mucous 
discharges preceding it. The discharge may be purely serous and 
devoid of odor. As soon, however, as ulceration has taken place 
the discharges excite suspicion. Their color is at first dark from 
the admixture of fragments of gangrenous tissue, then grayish- 
yellow, green, brown, or black, and of a sickening smell. The pain 
at the beginning is slight or wholly wanting. Violent pain occurs 
when the infiltration has involved the pelvic connective tissue. As 



MALIGNANT DISEASES OF THE FEMALE GENITALIA. 369 

a rule, the pain is proportionate in severity to the size and the hard- 
ness of the infiltrated area. The pain is most violent in slightly 
ulcerated carcinomata, or in those ulcerating late, when the hard, 
unyielding proliferations fill the entire pelvic cavity. 

To the true pains of carcinoma, of a pricking, lancinating, or 
burning character, are soon added those of chronic peritonitis occa- 
sioned by the inflammatory adhesions which form as soon as the 
neoplasm has invaded the peritoneum. The cervical canal in its 
involvement may be so narrow as to retain the secretions of the 
uterine cavity. Attempts on the part of the uterus to expel this 
dammed-up secretion excite violent colicky pain. Complete closure 
of the cervix may occur and hematometra or pyometra result, but 
this is very rare. 

The peculiar hardness of the abdominal wall is in a great meas- 
ure occasioned by the pain, and is characteristic of the later stages 
of carcinoma. The muscular tissues are strongly stretched, the 
intestines elevated, and the pelvic walls give to the touch a peculiar 
sense of hard resistance. 

The other symptoms are occasioned by the extension of the dis- 
ease to the neighboring organs. Usually the growth extends to the 
anterior vaginal wall and involves the bladder. As a result of the 
infiltration of the submucous layers of the bladder-wall the mucous 
membrane becomes irritable, and there is pain on micturition with 
vesical tenesmus. It is seldom that there is retention of urine. As 
the growth advances the ureters become compressed or share in the 
involvement; their calibre is narrowed, and hydronephrosis may 
result. Soon the cancerous masses in the bladder-wall ulcerate ; 
the tissues intervening between the bladder and vagina become 
progressively thinner, and finally are perforated. Frequently the 
rectum is also involved. Preceding the involvement of the rec- 
tum there are usually obstinate constipation and rectal catarrh from 
the pressure of the tumor obstructing its calibre. Following the 
rectal involvement is a progressive thinning of the recto-vaginal 
septum by ulceration and perforation, with the production of a 
recto-vaginal fistula. 

The patient may remain in excellent general condition until the 
disease has attained extensive development. Carcinomatous disease 
frequently attacks large and strong women. The nutrition of the 
body then soon begins to fail on account of the continuous drain of 
blood and serum from the diseased cervix, of the accompanying 



370 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

disturbances in the intestinal tract, and of the general degenerative 
effect of the cancerous disease on the blood. Usually there is 
obstinate constipation, although diarrhea may be present. There 
is a progressive loss of appetite, which may amount to an absolute 
disgust for food. Frequently there is vomiting, which may be the 
result of various causes. The stinking odor of the discharges is 
perhaps a decided element, and the uremic poisoning from pressure 
on the ureters has much to do with its production. The pain 
deprives the patient of sleep. Cachexia soon results from the 
frequent loss of blood and the profuse discharges. The legs become 
cedematous. At a later stage diarrhea sets in, and the patients lose 
flesh and strength rapidly. Fortunately for the patients, uremia, 
occurring from the slow occlusion of the ureters toward the close 
of the disease, clouds the intellect. They become more indifferent 
to their condition ; the anxious expression is lost ; the complaints 
of pain are less frequent; and they lie listless and dull upon their 
beds, without even attempting to change their positions. Gradually 
the cloud darkens, occasionally broken by a lucid interval, until 
death ends their pitiable existence. 

In the majority of cases death takes place from uremic poisoning 
when the ailment is left to run its course and the patient is not 
carried off by intercurrent disease. The ureters are found thick- 
ened, often to the size of the finger, and the pelvis of the kidney 
greatly distended with urine. Purulent peritonitis may occur, and 
hasten the woman's end before the cancerous disease has involved 
the ureters. Exhaustion is of course a large element in the causa- 
tion of death. 

It is difficult to estimate the course of the disease because the 
early stages are not recognized. As a rule, we may say that death 
occurs in from one year to one year and a half after the inception 
of the disease. 

Carcinoma of the cervix is usually of easy diagnosis, from the 
fact that it is, as a rule, fully developed and often far advanced 
when it comes under observation. In the early stages of its devel- 
opment it is difficult of recognition. The cauliflower or papillary 
kind is the easiest to be recognized. Here the quick growth, the 
irregular, knotted, or cauliflower shape, and the rapid disintegra- 
tion serve to make the diagnosis clear. As a rule, all sessile papil- 
lary or villous growths of the cervix are carcinomatous. 

The parenchymatous or nodular form of cervical cancer is more 



MALIGNANT DISEASES OF THE FEMALE GENITALIA. 371 

difficult of diagnosis. It is readily confounded with myoma if the 
nodules are situated in the patulous cervical canal or superficially, 
bulging the mucous membrane of the vaginal portion. A myoma, 
however, is of much harder consistency, and it is seated in normal 
tissue, while the softer carcinomatous nodules are surrounded by 
infiltrated and inflamed tissue. On incising the growth the myoma 
cuts with considerable resistance, while the carcinoma is soft like 
marrow. A positive diagnosis at times cannot be made until an 
excised nodule has been examined microscopically. 

The differential diagnosis between superficial or ulcerating car- 
cinoma of the mucous membrane of the cervical canal and long- 
standing cervical catarrh is arrived at with great difficulty. In the 
early stage of this form of carcinoma the appearance is the same 
in both conditions. The folds and markings of the catarrhal 
mucous membrane are perfectly preserved in cancer, though the 
submucous layers be involved, and the evidences of the malignancy 
only appear when ulceration has occurred. 

Severe long-standing cervical catarrhs, with thickening of the 
vaginal portion and nodular enlargements of the surface, frequently 
excite suspicion of cancer. On close examination it will be found 
that the nodules consist of closed follicles filled with mucus and the 
surface is covered with epithelium. The absence of ulceration 
indicates the benign character of these cases of advanced hyper- 
trophy of the cervix. Should the cervix be eroded, the diagnosis 
may be made by the character of the denuded surface. In cancer 
the margins of the ulcer are sharp and dentated, and the surface 
bleeds readily. The presence of numerous follicles, studding the 
entire cervix or the marginal zone of the ulcer, argues in favor of a 
benign character of the disease. In the digital examination of cases 
of long-standing cervical catarrh, the sensation of an irregularly 
degenerated, hard, carcinomatous growth may be imparted to the 
finger. On examination with the speculum, however, it will be 
noticed that the suspicious points are clothed with epithelium, and 
the absence of ulcers will clear the diagnosis. It is well to bear in 
mind that carcinomatous growths are easily broken up by the exam- 
ining finger, while chronic inflammatory changes resist even strong 
pressure. A positive diagnosis should not be given, however, until 
a careful microscopical examination has been made of pieces of the 
growth removed for that purpose. Care should be taken that the 
tissue for examination should not be removed too superficially. 



372 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

When ulceration has taken place the diagnosis is comparatively 
easy; but it must be remembered that carcinomatous nodules of the 
cervix may reach a considerable size before perforating the mucous 
membrane. On the other hand, large ulcerating myomata which 
are protruding from the cervix may so resemble carcinomatous 
growths as to excite grave suspicion. Diphtheritic inflammatory 
deposits upon the cervical portion and neighboring parts of the 
vagina may so closely resemble carcinoma, through the uniform 
swelling and ichorous discharge mixed with blood, as to make the 
diagnosis of carcinoma doubtful. 

It is often difficult to determine how far carcinomatous infiltra- 
tion has extended. The neoplasm often involves the pelvic connec- 
tive tissue much deeper than it appears upon examination. The 
extension of the growth is best determined by combined examina- 
tion through the rectum under ether narcosis. The mobility of the 
womb will also give valuable information on this point, for if that 
organ is firmly fixed the presumption is that the disease has invaded 
the peri-uterine tissues. By catching hold of the cervix with a 
tenaculum, and by dragging the womb down, much information 
can be obtained through the rectum as to the condition of the broad 
ligaments. 

Unfortunately, the patients suffering with carcinoma of the 
cervix come under observation so late in its course that the total 
removal of the growth is usually rendered impracticable by the 
extensive involvement of the neighboring tissues. The condition 
of the patient is then most unfortunate. There is almost unbear- 
able pain, insomnia, hemorrhage, progressive loss of flesh and 
strength, and foul odor from the discharges. This condition may 
long be protracted, or death from peritonitis or from some intercur- 
rent disease may relieve the patient from her sufferings. The only 
favorable prognosis is afforded by the earliest possible operation, 
when the disease is yet limited to the cervix and the whole womb 
can be removed. 

The treatment of carcinoma of the cervix is either radical or 
palliative. The radical treatment comprises the extirpation of the 
whole womb with enough surrounding healthy tissue to ensure the 
complete removal. 

As long as the disease is confined to the cervical tissue there are 
hopes of a radical cure, and, as has been stated, complete and thor- 
ough extirpation of the womb and all its appendages, together with as 



MALIGNANT DISEASES OF THE FEMALE GENITALIA. 373 

much contiguous healthy tissue as is possible, is the only treatment 
to be considered. The method of removal is either the total abdom- 
inal hysterectomy or the combined operation as described elsewhere. 
Vaginal hysterectomy is not a proper operation for this disease, as 
by it sufficient healthy surrounding tissue cannot be removed with 
the same certainty or safety as by the other methods. 

Palliative Treatment. — When the cancer has involved the va- 
gina, or the wall of the bladder or of the rectum is infiltrated, or 
when there is found to be involvement of the broad ligaments, the 
inference is legitimate that the lymphatics have also become infected, 
and all radical treatment is contraindicated. Unfortunately, the 
radical treatment applies to a very small percentage of the cases 
met with both in private and in hospital practice. The onset of the 
disease is so insidious that early symptoms are overlooked, hem- 
orrhages are referred to the " change of life " or to irregularities 
of menstruation, and the patients present themselves at last for ad- 
vice with such extensive involvement that a brief respite from suf- 
fering and a short prolongation of their lives are all we can offer them. 
Our aim in these cases should be to check the wasting discharges 
and hemorrhages, and make the patients as comfortable as possible 
for the short time they have yet to live. 

High amputation of the remaining cervix either by the knife or 
cautery will give remarkable temporary results. Patients will return 
home and for months remain free from hemorrhages, smelling dis- 
charges, and most frequently pain. So great will be the relief from 
suffering clue to pain, anemia, due to hemorrhage, and septicemia due 
to absorption of cancerous discharges that these women will often in 
a few months gain from twenty to fifty pounds of flesh. Ordinary 
simple or wedge-shaped amputation is impossible, as the disease has 
long since progressed far beyond the limits within which this opera- 
tion is performed. 

The method of high amputation was originated by Shroeder in 
1878. His technique is as follows : The cervix is exposed by 
a perineal retractor and the labia held apart by assistants. The 
cervix is seized in the grasp of a double tenaculum or volsel- 
lum forceps and traction applied, the womb being drawn down as 
far as the elasticity of the uterine ligaments will permit. A circu- 
lar incision is made from one-half to one centimeter beyond the 
margin of the diseased vaginal mucous membrane. There may be 
considerable hemorrhage from the divided vaginal arteries which 



374 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

will require the application of hemostats and ligatures. After the 
hemorrhage has been controlled it is easy with the finger to sepa- 
rate the cervix from the tissues front and back, traction being made 
upon the cervix all the while. The connective tissue here contains 
no large vessels and is easily separated. The cervix is then drawn 
strongly to one side, rendering tense the parametric connective tis- 
sue on the opposite side, which contains the uterine vessels. This 
tense tissue, being easily recognized by the touch, is surrounded by 
a ligature, as in the . operation for total extirpation. The man- 
euvre is best carried out by a half-blunt staphylorrhaphy or 
aneurysm needle. After tightly tying the ligature the included 
tissue is divided with scissors between the ligature and the cervix, 
and the ends of the ligature cut off short. This ligation should 
include the uterine artery. A ligature is similarly placed on 
the opposite side, and the tissues divided between it and the 
cervix. Frequently the tightly-stretched sacro-uterine ligaments 
interfere with the drawing down of the uterus. They may be 
included in a ligature and severed, when the uterus will readily 
descend. The ligatures should be applied as far from the cervix 
laterally as possible, so that the division of the tissues does not 
occur close to the cervix. The cervix is now transversely separated 
from the body of the uterus anteriorly as far as the cervical canal, 
and a stitch passed through the vaginal wall, the connective tissue, 
and the divided cervical wall, and brought out in the cervical canal. 
This, being tightly tied, provides the means for safely holding down 
the stump after complete separation of the cervix. Should there be 
any hemorrhage at this stage, it may be controlled by the applica- 
tion of several similar sutures. The posterior wall of the cervix is 
now cut through, and sutures passed as before around its circumfer- 
ence, uniting the mucous membrane of the vagina to that of the 
womb. As the upper end of the opened vaginal tube is much 
larger than that of the womb, the vaginal mucous membrane is 
thrown into folds by the sutures. On either side are openings in 
which the ligature strands lie ; these require each a stitch to effect 
closure. If the ligatures include the uterine vessels and are tightly 
tied, there should be very little bleeding in this operation. The lower 
segment of the womb may be removed by this method if desired. 
Douglas's cul-de-sac is frequently opened ; the author has opened 
it several times, but this misadventure did not increase the danger 
of the operation. The wound in Douglas's pouch should be imme- 



MALIGNANT DISEASES OF THE FEMALE GENITALIA. 375 

diately closed by a continued suture of fine catgut. The vagina 
is to be carefully cleansed with boiled water and tamponed with 
iodoform gauze. The tampons are removed and renewed, and the 
vagina douched at intervals of twenty-four hours. In from five to 
eight days the tampons may be discontinued, but the daily douches 
are persisted in. On the tenth or twelfth day the patient may leave 
her bed. The early removal of the stitches is a matter of no im- 
portance, and the longer they remain the easier is their removal. 
Usually they are removed on the eighth day. If catgut be used 
throughout, there is no need of paying any attention to them 
whatever, as the loop is absorbed and the knot then falls off. 

The steps of the operation are practically a combination of the 
first part in the vaginal hysterectomy with ligature and a simple 
amputation. A glance at the illustrations of these two procedures 
will render the steps clear. 

The high amputation may also be performed by the galvano- 
cautery knife. The method is as follows : After exposing the cer- 
vix with a perineal retractor, and having the labia held apart by 
assistants, the cervix is seized by a double tenaculum or volsellum 
forceps and drawn down. The position of the bladder is deter- 
mined by the introduction of a sound, and the site of the amputa- 
tion carefully selected, so as to avoid wounding the bladder or open- 
ing Douglas's pouch. If it be found that the retro-uterine tissues 
are involved and that the peritoneal cavity must be opened to effect 
the excision, the operation should not be abandoned, for the results 
of such operations are said to be attended with little danger. In one 
such case, in which a hole was burnt into Douglas's pouch, no 
febrile movement whatever took place. The cervix should be 
amputated first, however, and afterward the retro-uterine tissues 
should be excised. A slightly curved cautery-knife electrode is 
applied cold to the point of election, the circuit closed, and a cir- 
cular incision made, the cutting being finished without the removal 
of the knife. Should it be desirable to remove the knife in order 
that the direction of the incision be altered, the current should first 
be broken and the knife allowed to cool, in order to prevent hemor- 
rhage. 

After the circular incision has been made to the depth of about 
one-fourth of an inch the knife should be directed upward and 
inward, firm traction upon the cervix being kept up all the time. * 
The remaining stump will be funnel-shaped, and should be gone 



376 AN AMERICAN TENT-BOOK OF GYNECOLOGY. 

over again and again with a dome-shaped electrode to render the 
baking of the tissues more thorough. 

In cases requiring amputation above the internal os, the cervix 
should first be removed, the stump grasped on either side of the 
cervical canal, and the higher amputation proceeded with in the 
same manner as before. Thus it is possible by successive attempts 
to excise as high as is desired. The ragged edges are finally to be 
trimmed off by the cautery-knife and the cavity tamponed with 
iodoform gauze. The tampon is allowed to remain for forty-eight 
hours. The after-treatment consists in the use of antiseptic douches. 

Almost as good results can be obtained by those not familiar 
with surgical procedures so formidable, by the use of the curette, 
scissors, and Paquelin cautery. 

The ulcerating or vegetating cancerous masses may be rapidly 
broken up with the fingers and by scraping away with a sharp spoon 
curette. After quickly removing all the diseased tissue possible, 
the ragged edges are trimmed away with knife or scissors together 
with as much more of the disease as can be obtained. It is of im- 
portance to bear in mind the position of the bladder and rectum in 
cases of extensive involvement, as the infiltrated walls of these 
organs are readily perforated, thus rendering, by rectal or vesical 
incontinence, the condition of the patient more uncomfortable than 
before interference. After sponging the cavity dry, the raw surface 
is seared with the button-shaped end of the Paquelin cautery heated 
to a dull cherry-red heat, and the wound tamponed with iodoform 
gauze. The cauterization is repeated again and again, the aim being 
to char the tissues left behind as deeply as possible. This tissue 
subsequently comes away by slough. The dressing should be re- 
newed in forty-eight hours, and the vagina douched with bichloride- 
of-mercury solution 1 : 4000. After such treatment the gain in 
weight and strength is fully as much and as rapid as after high 
amputation : it has the advantage of being a much less formidable 
operation. The improvement lasts usually from three to six months. 
In a few cases we have known the respite to last for several 
years. 

The use of caustics applied on small tampons to the raw surface 
after curetting, or independent of this operation has been advised. 
Nitric acid, chromic acid, 5 per cent, solution of bromine, caustic 
potash, and saturated solution of chloride of zinc are the caustics usu- 
ally employed. After their application the vagina should be pro- 



LATE XVIII. 




Removal of Carcinoma of the Uterus by the use of the Galvano-cautery after the method of Byrne. 



MALIGNANT DISEASES OF THE FEMALE GENITALIA. 377 

tected by tampons wet in a saturated solution of sodium bicarbonate. 
In forty-eight hours the tampons are to be removed, and the parts 
dressed with iodoform gauze until the slough of the cauterized area 
separates. This usually takes place in from seven to ten days. The 
use of the Paquelin cautery seems, however, to meet every indica- 
tion and to be attended with less discomfort to the patient. 

When the disease returns, as it surely will, or originally, should 
for any reason the surgical procedure be refused or deemed inad- 
visable, an effort must be made to relieve the symptoms as far as 
possible with drugs. The success, however, is not very encourag- 
ing, and the nearer the end approaches the greater are the sufferings 
and the more horrible the condition. 

The fetid discharges are best relieved by douches of perman- 
ganate-of-potash solution, 3 to 6 drachms to the quart, of perox- 
ide-of-hydrogen and chloral solutions, or of suppositories of chloral 
and tannic acid, which on account of their irritant action must be 
used intermittently with the douches. Thymol solutions have also 
been recommended. 

For the hemorrhages, which are seldom fatal, yet always weak- 
ening and alarming, it is best to use douches of very hot water or 
of very hot vinegar. If these fail, the vagina may be tamponed 
with pledgets of cotton wet in a saturated solution of alum. Should 
this fail to control the bleeding, some cotton, which has been soaked 
in Monsel's solution and dried, may be placed upon the cervix and 
secured by a gauze tampon. The use of Monsel's solution is seldom 
required, and should never be resorted to if it is possible to control 
the bleeding by other means. It produces dense coagula which are 
liable to occasion fresh hemorrhage in their subsequent removal, or, 
if allowed to stay, undergo decomposition and add to the patient's 
suffering. 

To prevent erythematous eruptions from the discharges, the 
external genitals should frequently be cleansed with castile soap 
and warm water, washed with lead-water, and anointed with 
borated vaseline. 

The patients, beside local treatment, require tonics and easily- 
digested food. The bowels are prone to become constipated, and 
require special care. The pain, though modified by local treatment, 
is distressing and demands the use of morphia, The withholding 
of opium from these sufferers is cruel in the extreme, and either 
the administration of some form of the drug by the mouth or the 



378 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



hypodermic use of morphia in whatever quantities required, is 
demanded in every case. They have but a few months to live ; 
let these months be as comfortable as possible. 

Carcinoma op the Body of the Uterus. 

Carcinoma of the body of the uterus is less frequent than that 
of the cervix, and a more frequent condition than sarcoma. It is 
more a disease of advanced age than cervical carcinoma, and is 
not usually seen before the menopause. It may occur in nulliparous 
women, and is then usually found in sterile women who have passed 
the climacteric and in old maids. 

Fig. 226. 




Malignant Adenoma of the Uterine Mucous Membrane, beginning glandular epithelioma. 

The disease originates in the glandular element of the uterine 
mucous membrane, and may present itself as a polypoid degenera- 
tion of the endometrium or as a diffuse infiltration. It rapidly 
invades the deeper tissues, which become necrotic and are thrown 
off. From the rapid destruction of the uterine tissue the womb 
soon becomes converted into a crater-shaped carcinomatous mass. 
Adhesions form to the contiguous organs, and perforation may take 
place into the bladder and intestine or into the peritoneal cavity, 



MALIGNANT DISEASES OF THE FEMALE GENITALIA. 379 

thus causing rapidly fatal peritonitis. The disease extends into 
the tubes and involves the ovaries. Metastatic nodules in other 
more remote organs are frequent. 

Symptoms. — The first symptom is hemorrhage. Later on there 
follows a copious watery discharge which may be purulent and offen- 
sive. The discharge may be bloody-serous in character and desti- 
tute of odor, and both hemorrhage and discharge may be wanting. 
The secretions are more fetid when softened carcinomatous nodules 
become loose in the uterine cavity and are expelled from it with 

Fig. 227. 




Carcinoma of the Body of the Uterus. 



bearing-down pains. The pain differs widely as a symptom. In 
many cases it is wholly wanting. The pains of carcinoma of the 
uterine body are similar to those accompanying other uterine 
tumors. Lumbar and sacral pains are complained of, and fre- 
quently violent pains in one or both lower extremities. Paroxysms 
of pain, recurring at certain hours of the day, are characteristic of 
carcinoma when present, but do not always accompany the disease. 
They resemble the pains of uterine colic, and are occasioned by the 



380 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

abnormal contents of the womb. Attempts of the womb to expel 
its contents occasion especially tormenting pain. Later, when the 
growth involves the serous covering, peritonitic pains are added. 

On examination the uterus will be found uniformly enlarged. 
Later in the course of the disease metastatic nodules may be recog- 
nized as prominences upon its surface, or adhesions to neighboring 
organs render it no longer capable of being definitely outlined. 
The enlargement is usually not extensive, and in the earlier stages 
it is barely recognizable. The cervix is occasionally patulous, or is 
at times dilatable by the examining finger, permitting the growth 
to be felt in the uterine cavity and pieces to be removed. It may 
be hollowed out by the invasion of the disease, forming with the 
uterus a large cavity. 

The general health usually fails late in the course of the disease. 
Often extensive disease is found in well-nourished women. Three 
times has the author successfully removed the whole womb for this 
disease in women who were fat, ruddy, and the pictures of perfect 
health. In none of these cases was pain the prominent symptom, 
but repeated and very persistent dribblings of blood. In one case 
only was the hemorrhage even alarming. 

The diagnosis of cancer of the body of the uterus often pre- 
sents many difficulties. Where the uterus is regularly enlarged 
and there are no bad-smelling discharges, the case may easily be 
regarded as myoma, yet the attention will be attracted in many 
cases to the strikingly tense distension of the uterine walls occa- 
sioned by the rapidly-growing neoplasm. This condition recalls 
that of hematometra. 

When a uterus, at first regularly enlarged, develops upon its 
surface one or more knob-like projections and forms adhesions to 
the neighboring organs, the indications are clearly of malignant 
growth. The diagnosis will be made then, however, too late for 
radical operation. 

The whole clinical course of cancer of the uterus should excite 
suspicion. The return of irregular hemorrhages after menstruation 
has ceased, often for years, should arouse the suspicion of cancer if 
there are no polypi in the endometrium or cancer of the cervix to 
account for it. The eventual occurrence of bad-smelling discharges 
and the perceptible increase in the size of the womb will confirm 
the suspicion. On the introduction of the sound the irregularly 
degenerated surface of the growth may be felt, and frequently the 



MALIGNANT DISEASES OF THE FEMALE GENITALIA. 381 

sound, used without force, will penetrate the masses, and, indeed, 
perforate the womb, as happened once in our hands. These clin- 
ical symptoms in advanced cases are so clearly indicative of cancer 
that hardly a doubt should remain as to the diagnosis. 

Microscopical examination of excised pieces should always be 
made. The pieces are removed at different positions of the growth 
with a sharp spoon. The operation is attended with neither suffer- 
ing nor harm to the patient, and renders the diagnosis more certain 
before the corroborative symptoms of the later stages have developed, 
which place the patient beyond the pale of operative interference. 

Cancer of the womb, from a curative point of view, must be 
regarded in its incipient stage, before it has progressed to fixation. 
In the course of its advance the lymph-glands which lie behind the 
peritoneum of the posterior abdominal wall, and the lymphatics at 
the point of attachment of the ligamentum latum upon the abdom- 
inal parietes, are the first to become affected. The palpation of 
these glands is extremely difficult, if not impossible. So in cancer 
of the uterine body it can never be determined absolutely whether 
the radical operation will be attended with a return of the disease 
or not. It can be decided only that the performance of the opera- 
tion is feasible. For this reason the prognosis in cancer of the 
body is perhaps less favorable than in that of the cervix. Yet, on 
the other hand, cancer of the body of the womb is slower in attack- 
ing peri-uterine structures. 

The sole treatment for cancer of the womb, wherever situated, 
whether in the neck or the body of the womb, before infiltration of 
the adjoining tissues has taken place, consists in the complete re- 
moval of that organ with its ovaries and tubes by the abdominal 
incision or by a combined vaginal and abdominal incision. The 
vaginal operation is totally inadequate in the face of this disease. 

In uterine cancer, if the vagina is not implicated, if the disease 
has not travelled along into the broad ligaments, and if the womb 
has not been fixed by adhesions, the immediate and remote suc- 
cess attending the operation of the complete removal is an extremely 
satisfactory one, considering the character of the disease. The ave- 
rages of immediate and permanent recovery compete most success- 
fully with those of the excision of the breast for cancer. 

As regards permanent success, cancer of the breast is discovered 
earlier, and is therefore operated on earlier, while cancer of the 
womb is often not discovered until it has so far advanced as to have 



382 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

insidiously implicated contiguous and continuous structures. Even 
when it is discovered, being seated in an unseen organ, its dangers 
are not realized and operative interference is liable to be postponed. 
Hence one would infer a larger measure of permanent success in 
extirpation of a mammary cancer. Yet, from our own personal 
experience, and from a careful statistical inquiry into the experience 
of others, we are thoroughly convinced that the removal of the 
womb for cancer far surpasses, in its remote or permanent success, 
not only all other operations for cancer of the womb, but also all 
operations for cancer in other parts of the body. Nor need we 
wonder at this success, because the lip, breast, penis, and rectum, 
which are the favorite sites for cancer, are integral parts and parcels 
of the body, while the womb is to the body only an appendage, 
which is merely suspended by stays and guys, and these of a differ- 
ent or mongrel tissue. 

We all know how liable cancer is to return in the breast even 
when discovered early and the whole mammary gland has been 
removed. Cancer of the lip or of the penis behaves no better, 
while cancer of the rectum almost always returns, no matter how 
early or how thorough has been the extirpation of the gut. On the 
other hand, a careful study of the work in the hands of the principal 
gynecologists of the world shows a permanent recovery — after three 
or four years — ranging from 45 to 70 per cent. In view of these 
facts we are warranted — indeed, we are compelled by duty — to ope- 
rate whenever we can do so safely in a case of cancer of the womb, 
and that by the complete extirpation of the whole womb. Every 
other operation aiming at the removal of only the diseased portion 
of the womb is a delusion and a snare. 

Cancer of the Ovary. 

Carcinoma of the ovary is usually secondary to a carcinoma of 
the womb or of some other organ. Primary ovarian cancer may 
occur, however, and appears to have no relation with the age of the 
individual. It has been observed before puberty. Usually both 
ovaries are involved. 

Primary ovarian carcinoma appears in two forms — as a diffuse 
cancerous infiltration of the ovarian stroma, or as a tumor growing 
from the periphery of the organ. 

In the first form the ovary is usually uniformly converted into a 
cancerous mass, preserving its form, although it may reach an enor- 



MALIGNANT DISEASES OF THE FEMALE GENITALIA. 383 

rnous size. Ovarian cancers of this class have been observed as 
large as a man's head. Karely, several cancerous masses may form 




Section of an Ovary, showing its surface covered with papillomata. 

in the ovarian tissue, which, growing rapidly, give rise to an irreg- 
ularly shaped tumor. 

In the second form of ovarian carcinoma the growth forms a 
cauliflower-shaped mass which projects from the surface of the 

Fig. 229. 




Papillomatous Cystic Tumor of the Ovary. 

ovary. It consists of a papillary proliferation rich in blood-vessels 
and covered with cylinder epithelium. This form of carcinoma of 
the ovary leads early to ascites and to the infection of the perito- 
neum. 

Of much more frequent occurrence is the cancerous degeneration 
of cystomata of the ovary. These appear either as the epithelio- 
matous form, having its origin in the papillary proliferation of a 
cystoma, rapidly leading to infection of the peritoneum and to 



384 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

ascites, or as a pure glandular type of carcinoma forming in the 
tissue of the ovarian cystoma. 

The ovarian carcinoma soon excites profuse ascites and chronic 
peritonitis from its irritation of the peritoneum. It spreads rapidly 
by circumscribed nodular formation to the neighboring organs, and 
through the broad ligament to the pelvic connective tissue. It may 




Papillomatous Disease of the Broad Ligaments, completely hiding the appendages. 

perforate the covering tissues of the ovary, and proliferate, fungus- 
like, in the cavity of the pelvis. The epitheliomata infect the peri- 
toneum much earlier. 

The primary symptoms do not differ from those of benign 
enlargements of the ovary. The tumor grows, however, more 
rapidly. Symptoms of chronic peritonitis exist. A symptom of 
much diagnostic importance is the early cedema of the feet and 
ankles from pressure upon the great vessels of the pelvis. The 
condition of the patient continues to grow worse until death occurs 
from peritonitis, marasmus, stricture of the bowel, or from uremia. 

The marked distension of the abdomen from ascitic fluid usually 
first causes the patient to seek advice. Soft, compressible masses in 
Douglas's pouch may then be felt. It is usually necessary to draw 
off the ascitic fluid by a small median incision or by tapping in 
order to make an absolutely certain diagnosis. The relaxed abdom- 
inal walls then permit an easy examination of the pelvic organs, 
and the irregularly-enlarged ovary or cauliflower-growth may be 



MALIGNANT DISEASES OF THE FEMALE GENITALIA. 385 

clearly detected, if the process has not progressed so far as to involve 
the entire pelvis and render the ovary a highly probable point of 
origin. An important point in the differentiation between this and 
a benign ovarian tumor lies in the progressive and steady loss of 
flesh and strength. This, together with the ascites and the rapidity 
of the growth, generally renders the diagnosis almost certain. Pain 
is not a prominent symptom of this disease. 

The treatment instituted depends upon whether secondary 
involvement of the peritoneum has taken place. If this has not 
occurred, ovariotomy should be performed at once. Frequently, 
after opening the abdomen, the operator will find, to his disappoint- 
ment, the impossibility of complete removal. If the infiltrated 
base of the growth is to be felt extending into the pelvic cellular 
tissue, or- nodules are found in Douglas's cul-de-sac, the operation 
should be abandoned, as attempts at removal of the growth would 
only hasten the end. 

Sarcoma of the Ovary. 

Sarcoma of the ovary is of rare occurrence. It is usually of the 
spindle-cell variety and affects both ovaries. It has been observed 



Fig. 231. 




f both Ovaries 



in girls eight years of age. The growth develops from connective 
tissue of the ovarian stroma, which normally contains short spindle- 



386 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

shaped cells. Sarcomatous tissue is frequently found in dermoid 
cysts, and growths resembling sarcoma microscopically often follow 
their removal. The spindle-cell ovarian sarcoma is attended with 
considerable vascular development, which gives the growth a cavern- 
ous appearance. The Graafian follicles may become dropsical, and, 
increasing rapidly in size, produce a cystic complication of the 
sarcoma. 

The sarcomatous tumor preserves the shape of the ovary, and 
may reach a considerable size. Tumors of this kind have been 
reported weighing eighty pounds. 

The diagnosis is difficult. A large solid ovarian tumor is easily 
recognized. Such a growth is probably sarcomatous if of rapid 
growth, possessing a smooth surface, and attended with ascites, 
especially if the patient be young and both ovaries be tumefied. 
Progressive loss of strength and flesh, with or without pain, is of great 
significance. 

There are practically but two solid tumors of the ovary, fibroid 
and malignant; fibroid growths of the ovary are exceedingly rare. 
The presumption in the case of a solid tumor of this organ is there- 
fore in favor of malignancy. 

The teeatment is wholly surgical. Sarcomata of the ovary do 
not rapidly involve the neighboring tissues, nor do they give rise 
to early metastasis. After removal they are not so prone to return 
as the carcinomata. Still, one is not sure of complete cure by extir- 
pation even in- the most favorably appearing cases. The author has 
had perfect cures from the removal of the cyst; then, again, he has. 
seen the disease return very soon ; but in one case it did not return 
for five years, during which time the woman enjoyed good health. 



sLk "VLk 



888 



^njjm v,d hedhos 

id us 9rfi gaioiol 

^aoqs iJ3 iqm9ttB 



BENIGN UTERINE NEOPLASMS. 



Fibroid Polypi. 



Cervical. — These are always more or less pedunculated, generally 
with slender stems. True fibroid polypi arising from the cervix 
are not common. More generally is it the case that cervical polypi 
are of glandular origin. 

As in the illustration, the gross appearances of the growths 
where they contain much fibrous ^s^^ngl^^gpHg^ii- 

Fig. 2&ftfobii9 JuqIuiuI .b9ba9J8ib si 
;}'f9f[7if xelnb ael§ Ifi'i9a9'g bus 
iqyjoq 9S9fto 'io 9mo3 
h 98ubo oi SB gaol 03 9d 
isl-g 9di 9iiIaU .&viu-7 
^89fIT — .bmotimyS 
.gbio*idn suooumdns 

b98B919ui <9gTBfio8ib Sndl 

sdi rii jd§i9w "io 931193 b 

^IlB"I9a9§ 98nio*iq si 9§1Bdo 

garxoo suonnhfrnoo b 9d pin 

9snloTq ^"i9v t S9'§BdTiom9d sb 

bioidi-1 .snolutaq ^IlBi9n9g 

Small Muriform Polyp of the Cervix [(papillary fibroma with glandular hypertrophy). 

nant disease, and the diagnosis may rest entirely on the microscopic 
appearances. 




J fit) Of 

n 



Cervical polypi, being exposed to the vaginal filth, usii 
duce a nasty, purulent discharge, profuse and ill-smelling. There 
is always more or less 'general glandular ehdocervi'citis with them 1 , 1 
the cervix being as a rule widely gaping and eroded. They do 
not reach a large size. If the pedicle be long and the mass hang 1 
entirely outside the f ee¥vrx^tMripiat!6n of ^^ '^MyfeW 

and a spontaneous cure ensue. .b9inqoiJ 

Uterine.— These J ^»^rS!^ftrStaRM^ f,( bli^« [ «He 9 ifffiAus 
polypi already desbfl6®Ffe&# ^mtafeo'tiHf^as.^^fiey 19 ^^ 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



scribed by many authors 
forcing the submucous 



as the result of the uterine contractions 
fibroids into a pedunculated form — an 



attempt at spontaneous cure. The uterus being in a condition 



Fig. 233. 



m N 




Intra-uterine Fibroid Polyp. 

of chronic metritis is always more or less enlarged, and its cavity 
is distended. Purulent endometritis is a common accompaniment, 
and general glandular hypertrophy is usually present. 

Some of these polypi have short stems, but their pedicles may 
be so long as to cause the bulb of the polypus to hang from the 
vulva. Unlike the glandular variety, fibroid polypi are usually single. 

Symptoms. — These are very similar to those occasioned by small, 
submucous fibroids. There are pronounced uterine cramps, puru- 
lent discharge, increased menstruation, hemorrhage, backache, and 
a sense of weight in the pelvis, as common symptoms. The dis- 
charge is profuse generally, and the bleeding is marked. There 
may be a continuous oozing all the time, or the bleeding may occur 
as hemorrhages, very profuse and alarming. The cervix uteri is 
generally patulous. Fibroid polypi are not easily mistaken for 
other growths when once seen and felt. 

Treatment. — Fibroid polypi are not amenable to medical treat- 
ment. Pedunculated fibroid polypi from the cervix may readily be 
removed by torsion. Should the base be firm or broad, it may be 
severed with the scalpel and a few sutures taken to correct the 
hemorrhage and approximate the cut surfaces. 

Small polypi from the body of the uterus may also be removed 
by torsion, but it is better to combine with this curettage and gauze 
packing if the general endometrium be, as it usually is, much hyper- 
trophied. 

Large polypi are occasionally quite formidable affairs. In case 
the finger cannot be introduced into the vagina at all, owing to the 



BENIGN UTERINE NEOPLASMS. 389 

size of the growth, it is proper to cut away enough tumor to enable 
the passage of the finger and .stout forceps. The pedicle is sought 
for and secured by forceps, when the growth is to be cut away. The 
pedicle may be twisted or sutured. As these growths are unclean, 
irrigation and gauze dressings are indicated. It must not be for- 
gotten that in old women malignant disease is apt to supervene 
upon any long-standing inflammatory condition of the inside of the 
uterus. Therefore it is always well to submit the curettings and 
the polypus to the microscopist for examination. 

Uterine Fibroids. 
Pathology. — Uterine fibroids are composed of an increased 
growth in the fibrous and muscular structures of the organ ; they 




Uterine Fibro-myoma, microscopic view. 

are generally, then, fibro-myomata. They are non-malignant 
tumors, but not infrequently is malignant disease associated with 
existing fibroid. They may occur just beneath the uterine mucous 
membrane, or deeper in its walls, or immediately under the peri- 
toneum. They are then known as submucous, interstitial, or 
subserous. They are prone to occur in nests or groups, and the 
several varieties are very often associated; precise classification in 
such a case is not possible. In gross appearances these tumors 
are of a deep red color or pale. They are firm, and under the knife 
cut like gristle when the fibrous tissue predominates, but are less 
firm when the muscular fibres are in excess. Upon section the 
striations of bundles of fibre may be seen, -and nests of fibrous 
tissue bulge from the cut surfaces as nodules. Their walls may 



390 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



contain cysts filled with clear, bloody, or purulent fluid. They are 
prone to undergo various degenerative processes — cystic, myxo- 



Fig. 235. 




Submucous Uterine Fibroma. 



matous, fatty, and even calcareous degeneration. There are two 
forms of cystic degeneration — one due to myxomatous changes ; 




the other, more common, due to lymphangiectasia — distension of 
the intermuscular lymph-spaces. 



BENIGN UTERINE NEOPLASMS. 



391 



Fibroid and fibrocystic tumors occur of any size, from that of 
a pea to the largest, weighing one hundred and ninety-five pounds, 



Fig. 237. 




Large Fibrous Interstitial Tumor of the Uterus. 



removed by Severanu. They arise from any part of the body of the 
uterus, and less frequently also from below the os internum. Large 




A, Subperitoneal Pedunculated Fibroid ; B, left kidney : C, Wolffian cyst ; I), interstitial fibroid contained 
in the right cornu of the uterus ; E, insertion of the pedicle of the large tumor on a level with the 
left cornu; F, left ovary and round ligament ; G, right ovary and round ligament ; II, cervix. 



subserous tumors are covered with enormous veins, and all fibroids 
are generously supplied with blood. According to size and locality, 



392 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

Fig. 239. 




Interstitial Fibroid. 



they may form attachments to almost any of the abdominal organs. 
Pedunculated fibroids from torsion of the pedicle, may slough. 
In addition to the above degenerative changes, fibroids may 



Fig. 240. 




uini,' tlir cjilcniviiiis niiilulrs. 



BENIGN UTERINE NEOPLASMS. 



393 



become infected and undergo inflammation, with the production 
of pus, or even become gangrenous. Finally, the mucosa of the 
fibroid uterus may become epitheliomatous, or the connective tissue 
may be infiltrated with sarcomatous elements ; and it is not uncom- 
mon to find cancer of the cervix coexisting with fibroid of the body. 
The cell-proliferation arises from the adventitia of the arteries, and 
the tendency to it is probably congenital. 

Wyder has shown that there is nearly always an endometritis 
of a glandular, hypertrophic character, associated with fibroid. 




Pedunculated Fibroid with Abdominal Evolution : MS, fibroid lobe ; MC, fibro-eystic lobe. 



The Fallopian tubes are the seat of interstitial change also, and 
may contain bloody or purulent fluid, and the ovaries are usually 
enlarged, with thickened capsules. 

Various interstitial changes are produced in the important vis- 
cera, chiefly by obstruction to the vascular circulation, as fatty 
liver and nephritis. Large tumors are also associated with con- 
servative hypertrophy of the left heart. There are two forms of heart 
degeneration, which are supposed to exist in advanced cases, and 



394 



AN AMERICAN TEXT- BOOK OF GYNECOLOGY. 



known as brown and fatty degeneration. Fibroids occur before 
middle life as a rule, and have even been noticed before puberty. 

More or less peritonitis is to be found in connection with the 
large tumors, binding them to the viscera. The omentum espe- 
cially is prone to become attached to them, thus lending to the 
growths a new and increased blood-supply. Large blister-like 
accumulations of serum often occur just under the peritoneum 








Enlarged Blood-vessels on the Surface of a Multinodular Subserous 



adjacent to the sides of the large tumors, and more or less ascites 
accompanies them. 

Symptoms. — Some fibroids, even of considerable size, give rise 
to no symptoms at all for some time, the patient merely noticing in- 
crease in her girth. Symptoms are due to the situation rather than 
to the size of the tumor. Subserous tumors give rise to pressure- 
symptoms chiefly, while hemorrhage is the most marked symptom 
of the submucous and interstitial varieties. But one subject may 
present all the various forms. 

Pain. — This is very marked where the tumor causes a general 
distension of the uterine walls. Like all uterine pains, it is pro- 
ductive of hysterical symptoms. There are other pains, paroxysmal 
and from contraction of the uterine muscle, due to the irritating 
presence of the tumor. Local pain is less commonly attendant 



BENIGN UTERINE NEOPLASMS. 395 

upon the subserous variety. The greater the tension in the uterine 
walls, the more severe is the pain. Thus it frequently happens that 
there is less pain where the growth has become large and thus 
escaped from the control of the uterine muscle. 

Tumors of size growing from any part of the uterus cause pain 
from pressure on the nerves and adjacent organs. These pains 
radiate down the thighs and through the bladder and bowels from 
obstructed function in those viscera. Pressure-pains are most 
marked with tumors which are yet in the true pelvis. When the 
uterus and neoplasm have risen above the brim of the pelvis, they 
have a greater range of mobility. Menstruation and other bleed- 
ings increase the pains markedly in some cases. 

Hemorrhage. — The menstruation first begins to be increased in 
amount. After a while the flow is extended in time for a few days, 
and an observing patient will appreciate that she is using more nap- 
kins at each successive period. Soon intermenstrual bleedings occur, 
and at such irregular intervals that the patient will lose all record 
of menstruation. She will be free from hemorrhage for weeks, and 
then have a bleeding which will bring her to death's door. This 
hemorrhage is produced from the hypertrophied endometrium, which 
often is in a condition of general polypoid degeneration, but there 
may be profuse bleeding from a membrane which is atrophic. 
Vessels which in the normal endometrium are mere capillaries be- 
come here thin-walled arterioles. These bleedings are often the first 
symptoms of mural and submucous fibroids, even of those of small 
size. Subserous growths may attain considerable size before giving 
rise to marked bleeding. The occurrence of the menopause has a 
favorable effect upon these growths, but it often never occurs, and 
is always postponed by the tumor. Again, most tumors begin to 
produce marked symptoms at a time when the menopause should 
naturally occur. Moreover, the menopause may merely check the 
bleeding for a time, it recurring after a few years. 

Alternating with the hemorrhages is a leucorrhea. This may be 
a simple whitish discharge, or sanious or purulent according to the 
changes in the endometrium. It is frequently chylous, profuse, and 
particularly exhausting to the patient. 

Pressure-symptoms. — Tumors lying in the true pelvis obstruct 
the rectum, thereby producing retention of feces even for many 
days at a time, and inducing a form of systemic poisoning by the 
re-absorption of excreta — "retention toxicosis." Also, as a result 



396 AN AMERICAN TEXT- BOOK OF GYNECOLOGY. 

of this pressure, hemorrhoids are of common occurrence. The 
action of the bladder is interfered with by pressure on the urethra, 
producing thereby painful and difficult urination, with, ultimately, 
cystitis from retention. 

The presence of large fibroids so obstructs the return flow of 
blood from the legs that there is necessarily a compensating enlarge- 
ment of the veins of the abdomen. The ureters may be so obstructed 
as to produce hydronephrosis, and ultimately interstitial change in 
these glands, with albuminuria. Dropsy of the legs may occur from 
pressure alone, independently of kidney change. 

General Symptoms. — As a result of the repeated hemorrhages 
these patients are exsanguinated to a considerable degree. In some 
the bleedings are sudden and fierce. These suffer from attacks of 
syncope. In others there is a continuous dribble, with occasional 
floodings, and they present the worst appearance of all, inasmuch 
as there is no interval during which recuperation may occur. 
Many of them are in very good flesh, some even fat. But those 
who have large tumors are emaciated from locking up of the emunc- 
tories and loss of appetite. 

In large tumors producing pressure on the intestines there are 
the symptoms of anorexia, costiveness, foul breath, headache, and 
sometimes vomiting. Even in cases where there is no suppuration 
in the tumor, there may be rise in temperature ; but, as a rule, 
febrile manifestations are indicative of degenerative changes, with 
production of septic material either in tumor or viscera. 

Death from fibroid occurs either from asthenia, due to the con- 
tinuous loss of blood and pressure, or some complication, and even 
from sudden profuse hemorrhage. 

Diagnosis. — A. Submucous Fibro-myoma. — The hemorrhages 
are especially severe, and first attract the patient's attention. Irreg- 
ular uterine colic is also frequent. If the tumor is large enough to 
fill the pelvis, all the symptoms due to pressure are present. 

Examination is most satisfactory. The uterine canal is increased 
in depth. Rectal and abdominal palpation show the organ to be 
enlarged in all its diameters, and reveal its shape. Intra-uterine pal- 
pation is perfectly safe, and may be performed by one of two methods. 
That of Vulliet, by packing the uterine cavity each day with suc- 
cessively increasing pledgets of iodoform gauze, is efficacious, free 
from danger, but painful and slow. Failing to dilate the cervix 
sufficiently for intra-uterine examination by Vulliet's method, 



BENIGN UTERINE NEOPLASMS. 



397 



incision of the cervix and forcible dilatation are to be employed. 
Dilatation being of sufficient extent, the finger of one hand is intro- 
duced into the uterus, while the other supports the fundus above. 
The submucous fibroid will be found to have made for itself a 
depression on that wall opposite its origin, and the tumor will be 
felt as a smooth, rounded body. The examination finished, the 
uterus is irrigated and a light drain of gauze introduced. If it has 

Fig. 243. 





(Edematous Submucous Fibroid : a, portion of 
cavity of the uterus, covered by mucous 
cavity. 



uterus; c, tumor lodged in the 
ising above the surface of the 



been determined to remove the tumor by enucleation at a subse- 
quent day, or if there be too free hemorrhage, the uterus should be 
tightly packed with iodoform gauze. In this way the cervix will 
be kept open for future treatment. These submucous myomata are 
sessile, and never pedunculated. 

B. Interstitial Fibro -myoma. — Frequently a small tumor is 
accompanied by a general fibroid enlargement of the uterus, giving 
rise to the most severe symptoms, and yet the nodule projects into 
neither uterine nor pelvic cavity. The diagnosis here is difficult, 



398 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

and with the enlarged uterus the symptoms point equally to car- 
cinoma ; therefore a curettage for diagnostic purposes is proper, as 
it enables the microscope to differentiate absolutely between the 
hypertrophic endometritis of myoma and the cell-proliferation of 
cancer. The shades of difference between aggravated hypertrophic 
endometritis with enlargement of the muscularis as a sequence, and 
general hypertrophy of the muscular walls, with a small interstitial 
myoma and thickened bleeding endometrium as sequences, are very 
slight. The chief point in distinction is the exact amount of uterine 
enlargement. Bimanual examination under narcosis, aided by the 
microscopical investigation of pieces removed by the curette, should 
determine the question. At least it may enable us to eliminate can- 
cerous and tubal disease. 

Where the interstitial fibroids are large, increased depth of the 
uterine cavity, general enlargement of the uterus, and more or less 
irregularity in its contour, either exterior or on the mucous coat, 
will suffice to make the diagnosis plain. These tumors when large 
produce hemorrhage, expulsion pains, and hysterical manifestations, 
in addition to pressure-symptoms. 

C. Subserous Fibro-myoma. — These tumors are usually multi- 
nodular, and present a great diversity in arrangement. They may 
be sessile or pedunculated. The sessile tumors must be considered 
according to whether they extend between the layers of a broad 
ligament, into the bladder or into the pelvic cavity. 

The diagnosis of sessile subserous fibroids projecting free into 
the peritoneal cavity is easy, the nodule being readily felt upon 
bimanual examination and rectal touch. At the same time, other 
conditions are easily excluded. 

If the sessile fibroid grows from the anterior surface of the ute- 
rus and displaces the bladder, the uterus is usually retroflexed. 
The finger in the rectum may be made to feel the division between 
the uterus and fibroid, or the hand above the pubes may. But not 
always is this sulcus present, and the entire history and surround- 
ings must be critically considered in order that an accurate diagnosis 
may be made. 

Intra-ligamentous fibroids are exceedingly puzzling. They simu- 
late ovarian cysts, broad ligament disease, extra-uterine pregnancy, 
and tubal cysts. Those which project into the broad ligament from 
the side are not especially difficult of diagnosis. They are more 
firm than other tumors in this locality, and the depression above and 



BENIGN UTERINE NEOPLASMS. 399 

below between tumor and uterus may be felt. There is not the ten- 
derness which accompanies tubal disease, and there is more mobility 
when the nodule is small. Ovarian tumor, for many reasons, may 
be excluded. Extra-uterine pregnancy which has lasted a few 
months, especially if preceded by menorrhagia, is not easily differ- 
entiated from fibroid, for it has the same tense walls as fibroid. 
Although there is severe pain, yet it is not as lancinating as that of 
extra-uterine gestation, and is not followed by collapse, as in the 
latter. The pains of fibroid come on gradually, whereas the extra- 
uterine pregnancy first attracts attention by the sudden onset of the 
stabbing pain from the first attempt at tubal abortion. There is 
great difficulty in making the diagnosis sometimes, so similar are 
the histories of the two conditions. All fluid accumulations fluc- 
tuate, and are thus excluded. 

When the sessile intraligamentous tumor grows down against the 
floor of the pelvis, it exercises violent and painful pressure upon 
the structures passing under it. The uterus is lifted up and 
immovable. The tumor is not only sessile, but also attached to 
the pelvic floor. Here rectal touch is especially valuable. The cer- 
vix is often so drawn upon for tissue as to be a mere ending to the 
vagina and cul-de-sac. So firmly attached to the pelvis are these 
growths that they seem to spring from the pelvic fascia. Enchon- 
dromata and fibromata of the pelvic floor have none of the general 
symptoms which intra-ligamentous tumors produce, and may thus 
be rejected. 

Dermoid cysts under examination may suggest fibroid, but the 
subjective symptoms of the two conditions will suffice to differentiate. 

Pedunculated subserous tumors float free in the abdomen with 
long pedicles, or are joined to the uterus by a shorter and more 
firm bond. 

(Edematous tumors simulate ovarian cysts, but the fluctuating 
portions of the fibroid are limited, and there are parts of the tumor 
which demonstrate its character. The diagnosis is often utterly 
impossible. Unless the pedicle be very long and slender, the cer- 
vix grasped with the volsella and drawn down communicates at 
once its motion to the tumor ; with dermoids and other hard cysts 
it does not. The area of displacement of fibroid is below the pelvic 
brim, that of floating kidney above. Splenic tumors arise from the 
splenic area and may be traced to their origin. Cancerous and 



400 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

tubercular omental disease displaces the stomach downward, and 
there is no area of resonance save at the hypogastrium. The 
growth is more rapid than in fibroids, and hemorrhage is wanting. 

Many large fibroid and fibro-cystic tumors never give rise to 
hemorrhages, and the first and sole symptom may be the presence 
of the tumor. This is especially true of the fibro-cystic tumors, 
they causing, compared with the true fibro-myoma, but little bleed- 
ing. They have taken some time to grow, and coils of intestine 
are commonly in front of them, giving a tympanitic percussion-note. 
Almost invariably the cavity of the uterus is increased in depth, 
and rectal touch at least will demonstrate the attachment of the 
tumor to the uterus. 

Treatment. — Sometimes tumors are accidentally discovered, 
produce no symptoms, and never give rise to conditions requiring 
treatment. They remain innocent during all the woman's life. 

The treatment may be divided into non-operative and opera- 
tive. In the former class we shall mention but two methods of 
treating these growths — by the use of ergot and by electricity. 

Ergot Treatment. — The ergot is used both hypodermically and by 
the mouth, and is employed in every form of the tumor — in sub- 
serous fibroid for the purpose of causing shrinking, and in inter- 
stitial and submucous growths not only to cause diminution in 
size, but also, possibly, to cause expulsion of the growth per vias 
naturaks. 

Squibbs's aqueous extract (ergotin), dissolved 1 p;irt to 10 of 
water, and 1 grain of salicylic acid added to each half-ounce of 
solution, the whole sterilized, may be employed with a hypodermic 
syringe kept for that purpose. The syringe also should be care- 
fully sterilized before each application. 

Beginning with 1 grain a day, the dosage may gradually be 
increased, the uterine pain governing largely the amount used. The 
same preparation may be used in pill form associated with nux 
vomica or strychnia. Where the tumor is submucous and inter- 
stitial large doses of ergot produce sudden and severe uterine colic ; 
not so much impression is made, however, upon pedunculated 
fibroids. The depressing action of ergot upon the heart should 
not be forgotten, and for that reason it is wise to use strychnia at 
the same time. It is better to use a moderate dose continuously 
with weekly increases than to give enormous doses and intermit. 



BENIGN UTERINE NEOPLASMS. 401 

Thus, if a patient receives internally 3 grains of ergotin a day and 
1 grain hypodermically one day in the week, she should take 
enough to cause marked effect upon the uterine muscle. 

There can be no question as to the effect of the drug. The most 
careful observers are unanimous in testifying that it not only relieves 
symptoms, but in all cases reduces the tumor, and a number of cases 
are reported of the voiding of tumors under its use. There is but 
little danger in its use, and we have been able to find only two 
cases which died while undergoing this treatment. Hydrastis cana- 
densis is also highly spoken of as a substitute for ergot, in doses of 
20 minims of the fluid extract, three times a day. 

Ergot has no effect upon the fluid contents of fibro-cysts. 

Electricity. — The electrical treatment of fibroids is so technical, 
and requires such an assortment of instruments and batteries, that 
information on the manner of using it will be left to special works 
on the subject. Different authors give different instructions as to 
the strength of the current : they range from 15 milliamperes to 
250, or even more. The pain produced by the strong currents is 
excessive. As to the results of the procedure, the latest figures are 
given from the works of Keith, Englemann, Gautier, and others 
who are particularly skilled in the method. There were 372 cases : 
9 cured, 5 died. This is 2.4 + per cent, cured and 1.3 -4- per cent, 
died — too high a ratio of mortality and too low a ratio of cures. 
The percentage of cures about represents the possible percentage of 
errors in diagnosis. There is another certain percentage not men- 
tioned here, but which is, under careful investigation, growing. We 
refer to malignant disease associated with fibro-myoma. Electricity 
is admittedly not applicable to any form of cystic fibroma. 

Altogether, the method must be considered purely experimental. 
The above results are certainly not flattering. Surely better results 
have been obtained from the use of ergot, and infinitely better from 
the removal of the uterine appendages, with about the same rate of 
mortality. In all cases where the physician feels he would not care 
to attack these growths radically, in view of the poor results at the 
hands of those who are masters of the electrical method, we would 
certainly recommend the use of ergot or hydrastis to the exclusion 
of electricity, supplemented also by curettage in cases with severe 
hemorrhage, the results on both the tumor and general economy 
being excellent. 

The treatment of fibroids by galvano-puncture is no longer 



402 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY 



practised to any extent, and is to be condemned in an uncompromis- 
ing manner. 

Surgical Treatment. — Vaginal Enucleation. — This operation may- 
be applicable to tumors which may pass the pelvic outlet or those not 
larger than the fetal head. The method is limited to growths which 
are strictly submucous or covered by only a small quantity of mus- 
cular tissue. The cervix is to be dilated by daily packing with 
gauze, and at the time of operation its calibre may be still more 
increased by incisions and forcible dilatation. The operation is 
preferably done in the dorsal position. The patient should be pre- 
pared as for a hysterectomy. If there be not room enough, the 
uterine artery may easily be ligated (see Vaginal Hysterectomy), and 
the cervix split to the vaginal junction. The tumor being located, its 
capsule is seized with a bullet forceps and split with a scalpel from 
above downward. A blunt-pointed curved scissors is then used 
to loosen the capsule from the circumference of the tumor. The 
excess of capsule is then cut off with scissors. The tumor is now 



Fig. 244. 




Removal of 1 



by Muret'lliitinn. 



seized with the forceps, and attempts made to dig it out of its bed 
with the blunt scissors, the point being turned toward the tumor. 



BENIGN UTERINE NEOPLASMS. 403 

In this way, alternately snipping connecting fibres and using either 
the closed scissors or an enucleator, but all the time applying firm 
traction on the tumor, it may be loosened from its bed, with the ex- 
ception of a few fibres. It is then seized with a pair of strong forceps 
or hysterectomy volsella and twisted off. If the mass will not pass 
the cervix, it may be split. All loose shreds of tissue and capsule 

Fig. 245. 




\: 



\. 



Subperitoneal Nodular Fibro 



should be cut away, the finger introduced to see how much damage 
has been done, and the uterus washed out and packed with iodoform 
gauze. The hemorrhage is best controlled by the packing. The 
great danger from this operation has heretofore been sepsis, a thing 
we can now avoid. Even perforation of the uterus is not espe- 
cially dangerous. Many tumors now removed by hysterectomy 
were formerly dealt with by this procedure. The after-treatment 
consists of the administration hypodermically of ergo tin, frequent 
irrigation, and gauze packing invariably instead of drainage tub- 
ing. Most tumors formerly subjected to this operation are now 
preferably extirpated from above. 

Applicable to tumors of the submucous and interstitial variety, 
morcellation will never occupy a place in surgery. It essentially 
involves incomplete piecemeal removal of the growths by forceps, 



404 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



scissors, and knife, after severe preliminary incisions in cervix and 
uterus. 

Small interstitial fibroids may be removed by total vaginal hys- 
terectomy'. The operation may be indicated when the mass is very 




Method of Removal of a Subserous Uterine Fibroid, stitches in place ready for tying. 

small, gives great pain, which produces profuse bleeding, or is septic. 
Cceliotomy is, however, preferable, as a general rule. 

Myomectomy. — It will occasionally happen that the fibroid is 
attached to the uterus by a pedicle so small as to warrant removal 
of the tumor through the abdominal incision, with the saving of the 
uterus. The pedicle is subjected to a V-shaped incision and the 
tumor removed. Sutures of heavy silkworm-gut or silk are then 
used to unite accurately the sides of the pedicle. If there is com- 
plete control of the bleeding without the appearance of strangula- 
tion by the sutures, the uterus is returned and the abdomen closed. 
Large pedunculated fibroids with stout pedicles may be treated dif- 
ferently, thus eliminating the great danger of myomectomy — hemor- 
rhage. An elastic ligature or ecraseur is thrown around the pedicle 
a little distance from the uterus, and the tumor cut away. The 
pedicle is brought up into the wound, transfixed with stout pedicle 
needles, and the wound accurately closed around the stump, thus 
treating the stump extra-peritoneally. (See Supra-vaginal Hys- 
terectomy.) 

The procedure may also be applicable to small (single or multiple) 
interstitial fibromata. The objections to myomectomy are, that 
uterine fibroids are almost universally multiple, and, no difference how 
many nodules are removed, the chances are largely that others have 



BENIGN UTERINE NEOPLASMS. 



405 



been unobserved and left behind to reproduce the trouble. In the 
vast majority of even small interstitial fibromata the complete enucle- 
ation of the tumors is a matter of great difficulty and results in much 
traumatism. The causes which in the past have rendered hysterec- 

Fig. 247. 





A, Enucleation of an Interstitial Myoma : B, Disposition of Sutures after Enucleation. 



tomy so fatal are present in myomectomy — i. e. the great difficulty, 
almost impossibility, of placing stitches in uterine tissue with any 
degree of security. 

Supra-vaginal Hysterectomy. — Extra-peritoneal Amputation 
Method. — This necessitates the treatment of the stump extra-perito- 
neally. The abdomen is opened and the uterus and tumor are turned 
out through the incision. If necessary to accomplish this, the broad 
ligaments are ligated between two ligatures and a rubber ligature 
drawn taut, or an ecraseur is applied around the neck of the uterus. 
In fastening the rubber ligature one knot is tied and a stout silk thread 
is thrown over it ; then the second knot in the rubber ligature is 
tied, and the silk thread tied over this second knot. The same may 
be accomplished by grasping the knot in the bite of a pair of 
hemostatic forceps. Thus slipping is prevented. If the ecraseur 
is used, it is carefully tightened. The peritoneum two or three 
inches above the constricting wire is incised completely around the 
tumor, the broad ligaments being by this means allowed to retract. 
The tumor is then drawn further up out of the incision, thus form- 
ing a smaller and better pedicle. Transfixion pins are made to per- 



406 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



forate the pedicle immediately above the wire, and the tumor is cut 
away about an inch above the pins. The stump is held high in the 



Fig. 248. 




Knot of Rubber Ligature secured from Slipping by Application of Silk Ligature. 

lower angle of the wound, and inspection made of the constricting 
wire to see that it does not include the bladder or ureters in its 
grasp. If in proper position, it may be allowed to remain perma- 
nently, but if not satisfactory, it is loosened and applied at a higher 
level ; the transfixion pins are shifted to a higher point at the same 
time. Should the stump be too large, it must be reduced to a size 

Fig. 249. 




Serre-nceud for Hysterectomy. 

not greater than an inch or two in diameter by cutting the muscular 
and fibrous portions away piecemeal, the wire being carefully tight- 
ened during the procedure. The peritoneum is then closed by 
stitching it to the serous surface of the pedicle below the wire, by 
means of a single silk or catgut suture. The peritoneum of the 
pedicle is closed by drawing it up over the stump by means of a con- 
tinuous whipped silk suture. Throughout the whole procedure the 
ecraseur is continually tightened by turning the screw. Unless this 
precaution be observed the tissue of the stump shrinks under the 



Fig. 1. 



PLATE XIX. 





H 




Fig. 3. Fig. 4. 

EXTRA-PERITONEAL TREATMENT OF THE STUMP AFTER SUPRA-VAGINAL HYSTERECTOMY. 

Fig. 1.— Transfixion pins and serre-nceud in place prior to removal of tumor. 
Fig. 2— Abdominal peritoneum stitched to peritoneum of stump below wire. 
Fig. 3.— Peritoneum closed ; abdominal' stitches in place. 
Fig. 4.— Abdominal wound closed; stump in process of closure. 



BENIGN UTERINE NEOPLASMS. 407 

pressure of the wire, and bleeding would soon occur. If the rubber 
ligature be used, this precaution need not be observed. The abdom- 
inal walls are closed in the usual way by interrupted silkworm-gut 
sutures, passing through all the tissues but the serosa. After the 
stump and surroundings have been thoroughly dried an iodoform 
gauze dressing is applied. Pads of gauze are slipped between the 
transfixion pins and the skin, and are also packed carefully about 
and over the stump, iodoform having been freely dusted over and 
rubbed into the stump. The whole is covered with a thick gauze 
pad and held in place by a three-tailed abdominal binder. 
This operation can be performed very rapidly, and may be applicable 
to all tumors with the exception of those which burrow between 
the broad ligament folds, and septic tumors, where the sepsis involves 
the neck or pedicle. The pedicle dries up and gradually melts off 
into the dressings or comes away as a solid mummified mass. The 
first dressing is made on the eighth day, when the stitches are 
removed, the ecraseur having been kept tight by turning the key 
several times daily. The stump is ready to come off in from two 
to three weeks. If it does not come away itself in that time, it is 
best to remove the wire and pins and cut it away. 

The stump sinks deeply into the pelvis, leaving a tube of granu- 
lating tissue, which is packed with gauze and which gradually closes. 
The question of drainage must be settled by the necessities of each 
individual case. As a rule, it is unnecessary. 

There is, of course, a break in the parietes at the position of the 
pedicle which may subsequently form a hernia ; these patients 
should wear an abdominal pad, and should be kept in bed not less 
than six weeks or two months after the operation. Occasionally 
also a fistulous opening may remain from the cervical canal to the in- 
cision, through which air may pass up and down on exertion ; this is, 
however, of rare occurrence, the greater danger being that of hernia. 

Intra-abdominal Amputation Method. — The patient is placed in 
Trendelenberg's position, the abdomen opened, and the tumor deliv- 
ered if possible. If this cannot be accomplished, the first steps of the 
operation are carried out with the tumor in situ. A single ligature 
is passed through the broad ligament near the pelvic wall and tied, 
not being passed deep enough to include the uterine arteries. Another 
ligature is made to transfix the broad ligament near the uterus, and 
tied. The tissue between these two ligatures is cut through, and 
the same procedure is repeated on the opposite side. In this ma- 



408 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



neuvre the uterus is freed from its attachments to the pelvic wall, 
and the two ends of the ovarian vessels are safely included in the 
ligatures. The knife is now run lightly around the tumor just above 
the peritoneal reflexion of the bladder in front and a little lower 
behind, and the peritoneum stripped down, thus forming two flaps. 
The uterine arteries are next ligated as they pass between the cervix 
and the ureter, the ligature being passed close to the cervix, in order 
to avoid any possibility of including the ureter in its grasp. The 



Relation of the ('refers and T'terine Arteri 
C, cervix uteri, displayed by n transverse 
bladder at (lie level of the entrance oft! 
tissue are seen to unite it laterally witli 
covered by peritoneum which adhered I 




Ur, ureter; A V, uterine artery; 
nil cul-de-sac ; V, section of the 
'a, vagina : two bands of fibrous 
lish in the cervix the part not 



ligature may be passed between the flaps of peritoneum thus formed 
or outside of them. One is placed on each uterine artery and 
is securely fastened. This is the most important step in the 
operation. The tumor is now amputated on a level with the 
ligatures on the uterine arteries by a V-shaped incision, the 
point of the V being carried well below the point of liga- 
tion. (See Plate XX.) The cervical canal is charred with a 
Paquelin cautery or disinfected with a bichloride-of-mercury solu- 
tion, in order to avoid any chance of septic infection from that source 




Fig. 1— Supra-vaginal Amputation of the Uterus: first step. Position of second ligature shown 
Fpj. 2— Supra-vaginal Amputation of the Uterus : cervix amputated bj wedge-shaped incision. 



BENIGN UTERINE NEOPLASMS. 



409 



during the subsequent manipulations. The cervical flaps thus 
formed are now brought together with a continuous suture, which, 
after closing the cervix, is carried along, whipping the cut edges of 
peritoneum together from one side of the pelvis to the other. (See 
Plate XXI.) By this procedure the cervix, the two ligatures on 
the uterine arteries, and at times even the ligatures on the ovarian 
arteries, are turned under the peritoneum, thus becoming extra-peri- 
toneal. The abdomen is closed without drainage. 

In intraligamentous fibroid tumors or bad (chronic) pelvic in- 
flammatory conditions a modification of this procedure is at times 
invaluable. The modification is, however, accompanied by such 
technical dangers and difficulties that as a routine practice — except- 
ing in the hands of an expert — it is not to be employed. It should 
never in the inflammatory cases be the method of choice, but 
always that of necessity. 

Fig. 251. 




Left ovarian vessels tied, vesical peritoneum divided and pushed down, and left uterine vessels ligated. 
Cervix amputated and uterus pulled up and out, exposing right uterine artery, which is clamped 
an inch above the cervical stump. The two following steps are clamping the right round ligament 
and right ovarian vessels, when the mass is removed. 

The operation (see Fig. 251) is begun as above by tying off the 
ovarian artery on the free side of the uterus, cutting through the 
broad ligament down to the uterine artery on the same side, and 
ligating it as before. The ligated uterine artery is now severed, and 
by drawing the uterus forcibly to the opposite side it is amputated at 
its neck. The bladder is freed from the uterus in the usual manner. 



410 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

Immediately on amputating the uterus the opposite uterine artery 
comes into view and is grasped with a pair of forceps. This artery 
is at once severed, and by continued strong traction on the uterus 
the broad ligament on this side is torn through in an upward direc- 
tion until the ovarian artery is reached. This artery, together with 
the round ligament, is caught with forceps, and the remainder of the 
broad ligament cut through. Ligatures at once replace the forceps, 
and the operation is completed as in the ordinary procedure. The 
danger in the operation lies in a failure to find the vessels and grasp 
them in forceps, and in severing the ureter. An expert will know 
how to avoid these dangers. The ordinary surgeon will succumb to 
them not infrequently. In intraligamentary neoplasms and in pel- 
vic inflammatory conditions in which the adhesions are so universal 
as to make the line of division between the sigmoid and rectum and 
the diseased masses too uncertain to venture on breaking up the mass, 
or are so dense as to necessitate the use of too great force, this procedure 
will be found to render apparently hopeless cases comparatively easy. 

There are three elements in the intra-abdominal amputation opera- 
tion worthy of note : its blood lessness without elastic temporary 
ligation, absence of raw surfaces from dissecting off the bladder, and 
avoidance of ligatures about the cervix, which tissue is free from the 
possibility of sloughing. It has all the advantages, then, and none 
of the drawbacks, which attach to all other methods of treating the 
pedicle intra-abdominally. We believe it to be the ideal operation 
of its kind. This procedure may be employed in any and every 
condition in which it is desirable to remove the uterus, except in 
the presence of malignancy or tuberculosis of the uterus. 

When considering the intraperitoneal operation, and in view of 
the ease with which the vagina may be rendered sterile, the question 
naturally suggests itself, " Why not go a little farther and remove 
the cervix too?" 

Total Abdominal Hysterectomy. — The patient is to be prepared 
as for both a yaginal hysterectomy and cceliotomy. Here, again, as 
many times before, stress is laid upon the importance of thoroughly 
cleansing the vagina and the difficulty in doing so by the usual 
methods. Trendelenberg's posture occupies to this operation what 
Sims's does to vesico-vaginal fistula : it renders the operation not 
only possible, but comparatively easy. But two instruments need 
be mentioned as supplementary to the ordinary ovariotomy set: blunt 
and sharp Deschamp's needles for ligating en masse. 




Fig. 4. 



Fig. 3.— Supra-vaginal Amputation of the Uterus : cervical canal being closed by sutures which arc buried 
by subsequent sutures. 

Fig. 4.— Supra-vaginal Amputation of the Uterus: peritoneal edges of the stump in process of being 
whipped together, the lower slump being buried under the peritoneum. 



BENIGN UTERINE NEOPLASMS. 



411 



The objective points are the two ovarian and two uterine arteries, 
for these furnish the main blood-supply of the uterus and tumor. 

The operation which will be described may be applicable to all 
cases of fibroid tumor, intraligamentous as well as others, and to all 
other diseased states of the uterus and adnexa where it is desired to ab- 
late the uterus together with the adnexa through the abdomen. The 
typical operation will first be described and then its modifications. 




Deschamp's Needles. 

Operation. — The uterus is curetted and irrigated, but not packed. 
If the cul-de-sac is readily accessible, it may be opened through the 
vagina aud a wad of iodoform gauze inserted into the opening. 
The patient is placed upon a Trendelenberg table. While the 
assistants prepare the field of operation the operator disinfects 
himself again. 

Upon entering the peritoneal cavity- the patient is thrown into 
Trendelenberg's posture and the intestines forced into the abdomen, 
where they are held by large gauze pads. The pelvis being freed 
from intestines, the operator carefully inspects its contents, and close 
to the pelvic brim the ovarian arteries and veins are secured by single 
ligatures of fine silk. (See Plate XXIII.) A ligature is thrown 
around the ovarian vessels close to the cornua of the uterus. Near 
the first ligature and outside the ovary and fimbriated end of the 
tube the operator begins the section of the broad ligament. He 
cuts through the broad ligament close to the uterine-ovarian arterial 
anastomosis at the side of the uterus. The ovarian artery upon the 
other side has been similarly secured, and the broad ligament di- 
vided as described. This leaves both ovaries and tubes attached to 
the uterus. The operation up to this point is precisely similar to 



412 



AN AMERICAN TENT-BOOK OE GYNECOLOGY. 



the intra-abdominal supravaginal hysterectomy. The posterior 
cul-de-sac is now entered, or, if it has been opened at the time the 
uterus was curetted, the gauze plug is withdrawn and two fingers 
are inserted into the vagina through the cul-de-sac. The ends of 
the fingers are hooked beneath the cervix and make upward pres- 
sure against the anterior face of the cervix. The operator now 
begins the separation of the bladder from the uterus. In doing 
this the fingers in the vagina will be of material assistance in map- 
ping out the relations of the parts. A crescentic incision is made 

Fig. 253. 




th ovarian arteries are tied, but the ligature upon the 
the bladder lias been dissected away from the uterus 
course of the uterine artery, which is seen to cross 
broad ligament, The uterus is pulled to the right. ( 



The cul-de-sac is opened, and 
jnt has been split to show the 
ssage beneath the base of the 
of an operation.) 



from side to side across the anterior face of the uterus just above 
the utero- vesical fold. Laterally this incision stops short of the 
sides of the uterus. Having severed the peritoneum and loose fascia 
beneath it down to the uterine tissue proper, the operator dissects 
the bladder away from the uterus with the ends of two fingers. In 
doing this he is careful to keep the points of his fingers pressed 
hard against the uterus, and in this way avoids wounding the 
bladder. After the vagina has been entered in front, the fingers 
are withdrawn from the vagina and the two indices are inserted into 
the posterior cul-de-sac, while the middle fingers are placed between 
the bladder and uterus. The hands are back to back, and, as the 
operator separates them by pushing outward, he pushes away from 




Arterial Blood-supply of the Uterus and Adnexa : O.A., ovarian artery : a', a', a', branches to ampulla of 
Fallopian tube; c'.c'. c', branches to ovary: c, branch to fundus: d, branch anastomosing with uterine; 
6, branch to round ligament : e, uterine artery ; g, g, g, vaginal arteries : 6, b. azygos artery of vagina. 



Fig. 2. 




Venous Blood-supply of the Uterus: b. uterine artery, c, vaginal artery. 



BENIGN UTERINE NEOPLASMS. 

Fig. 254. 



413 




The Deschamp's needle circles the strip of tissue to the left of the cervix, which contains the uterine 
artery, bv passim: through th<- «.i.i'ii cul-de-sac behind, across the vagina, to emerge from the opencer- 
vico-vesical space. The ureter is well shown at the outer end of the rent in the broad ligament. 
(From a photograph of an operation.) 

the uterus all loose tissue upon each side, and this he does until he 
finds the uterus entirely free except at its lateral margins. He may 

Fig. 255. 




The left uterine artery has been tied en masse and the uterus cut away from all attachments on the left. 
The uterus is tilted far over to the right. The I>eschamps nee, lie is pa-sin- through the base of the 
right broad ligament to secure the right uterine artery. Both ovaries and tubes are seen. (From a 
photograph of an operation.) 

now proceed in one or two ways : He may ligate the uterine artery 
either en masse or in continuity upon one side between the folds of 
the broad ligament and about half an inch from the cervix, then cut 



414 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

away the cervix, and ligate the uterine artery in a similar manner 
upon the other side, and remove the uterus and adnexa ; or, if he 
be cramped for space or is embarrassed by capillary bleeding, he 
may secure each lateral pedicle containing the uterine arteries with 
heavy forceps and remove the uterus, subsequently ligating the ute- 
rine vessels after the uterus and adnexa are out of the way. Much 
time will be saved if the operator secures the stump, holding the 
uterine arteries by ligatures applied to the tissues en masse, and 
without seeking to pick the uterine vessels out. In doing this he 
uses very heavy braided or twisted silk and ties it with great force, 
the loop circling all the tissue upon each side of the cervix. The 




The completed operation. Both ovarian arteries are shown tied and the ligatures cut short. The stumps 
of the broad ligaments containing the uterine arteries are drawn down into the vagina. (From a 
photograph of an operation.) 

ligatures on the ovarian vessels are cut short, while those upon the 
uterine arteries are left long and turned down into the vagina. The 
vagina is filled with iodoform gauze, the upper end of which, nicely 
smoothed over, protrudes but a fraction of an inch above the incis- 
ion in the vagina. If the azygos artery on the posterior vaginal 
wall is large enough to spout, it is secured by catgut ligature and 
any bleeding points on the bladder wall are similarly tied. The 
pelvis is wiped dry and the patient lowered into the horizontal pos- 
ture. It will now be seen that the bladder and rectum fall together, 
completely shutting from view the vaginal wound and stumps of the 



BENIGN UTERINE NEOPLASMS. 415 

uterine arteries. The gauze pads are removed from the abdomen 
and the abdominal incision is closed (see Technique). Instead of 
drawing the uterine artery stump into the vagina and packing with 
gauze, the edge of the vaginal mucous membrane may be whipped 
together by a continuous catgut suture, and over this the edges of the 
peritoneum may be similarly united, burying the stumps of the 
artery between the vagina and peritoneum. By this procedure sub- 
sequent attention to the wound is dispensed with. The ligatures on 
the arteries have of course been cut short. (See Plate XXV. ) The 
urine is drawn and the patient put to bed. On the eighth day, if 
the temperature has been normal, the patient is placed in the lith- 
otomy posture and the vaginal dressing changed. The ligatures on 
the uterine arteries, if they have been left long and turned into the 
vagina, may be cut after this at any time or may be allowed to come 
away later. Traction upon them is not to be made. The mass of 
lymph which forms about the vault of the vagina implicates the bases 
of the broad ligaments which contain the stumps of the uterine arte- 
ries, and the resultant scar holds the vault of the vagina high up. 

Where very large fibroids are to be dealt with, it is advisable to 
eventrate the tumor before securing the vessels or attempting the 
ablation. In certain of these cases the tumor may be constricted 
by a stout elastic ligature applied above the cervix and the great 
mass of tissue removed. This procedure is particularly applicable 
where the larger tumor of a nest of growths is pedunculated. 

The operation for intraligamentous fibroids, proposed by Pry or, 
proceeds as described up to the point of securing the ovarian 
arteries. This artery is secured upon the free side only at this 
time. After this is done the operator dissects away the bladder 
from in front and ligates the uterine artery upon the free side. 
He now cuts the uterus away upon this side, opening the vagina 
as freely as possible. In order to secure the uterine artery 
upon the side of the intraligamentous nodule, he has an as- 
sistant tilt the uterus far over to the side of the nodule, so as to 
expose the interior of the vagina. The sharp Deschamps needle, 
threaded with stout silk, is passed close to the cervix up to the 
sulcus between the cervix and intraligamentous growth. The 
needle is forced around the uterine artery and emerges into the 
vagina again. It is tied and the cervix cut loose. It is now a very 
easy matter to peel the nodule out of the broad ligament without 
causing hemorrhage, and, when once freed, the uterus is held by 



416 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

the folds of the capsule of the nodule. A few strokes of the scis- 
sors applied upon the anterior and posterior faces of the uterus close 
to its side will take the uterus and tumor away. If the Fallopian 
tube be spread over the capsule, its removal is not attempted, but 
the ovarian artery on this side is tied close to the cornu. The ope- 
rator seeks to avoid splitting the capsule of the nodule, for in doing 
this he severs large venous sinuses and runs the risk of cutting a 
possibly misplaced ureter. The venous sinuses must be ligated if 
cut, and this conduces to the formation of sometimes enormous 
hematoceles beneath the peritoneum. Sometimes the tumor, as it 
grows out into the broad ligament, pushes the uterine and ovarian 
anastomosis outward. In such a case the uterine artery will still 
be secured by the Deschamps needle applied to the sulcus between 
the tumor and cervix. Although the uterine artery is always at the 
sulcus mentioned, its anastomosis with the ovarian artery and its 
branches to the cervix may be displaced outward by the intra- 
ligamentous nodule. But these branches are rendered dry by the 
ligation of the ovarian artery above and of the uterine below. 
Hence they cause no bleeding when the nodule is pulled out. The 
operator, not being positive of his anatomical relations, must adopt 
the only safe method of enucleating the fibroid and removing it 
with the uterus. So long as he avoids incisions into its capsule and 
injury to the periphery of the capsule, he will not wound the ure- 
ter and will develop no bleeding of moment. Heretofore it has been 
the custom to split the capsule of the tumor above and shell out the 
nodule from between the severed folds of the broad ligament. In 
doing this there is much time lost, a good deal of hemorrhage de- 
veloped from the large sinuses that cover these nodules, and very 
often has the ureter been wounded. This latter structure may lie 
beneath the nodule, over it, in front of it, or even posteriorly. We 
never know just where to find it, and there is always great risk of 
wounding it. There is, however, one spot in which it is never 
found, and that is directly against the cervix in the sulcus formed 
by the junction of the tumor and the uterus. The position of the 
uterine artery to these growths is constant. It lies beneath the 
tumor, and is always secured by the ligature applied as described. 
The capsule of the fibroid nodule collapses after the uterus is removed 
and requires no attention. The abdominal pressure causes it to 
remain closed, and drainage from its cavity is carried away by the 
vaginal dressing. 



PLATE XXIV 
Fig. 2. 




Fig. 3. 

Fig. 2.— Total Abdominal Hysterectomy: second step. Vagina opened anteriorly, with the index finger in 
the vagina, while the ligature is being placed about the uterine artery. 

Fig. 3.— Total Abdominal Hysterectomy : ovarian and uterine arteries ligated and uterus removed, leaving 
the vaginal vault opened, 



BENIGN UTERINE NEOPLASMS. 417 

Fibroids dissecting into the broad ligament, posteriorly beneath 
the peritoneal folds of Douglas's cul-de-sac, anteriorly into the 
bladder, or laterally toward the pelvic walls, are the most formid- 
able growths the surgeon meets. They are not amenable to the 
tardy benefits to be derived from medicinal treatment or the opera- 
tion of salpingo-oophorectomy. 

Fig. 257. 




A 
Intraligamentous Fibroma : A, abdominal variety ; B, pelvic variety. 

They can be removed by but two procedures : either by total 
extirpation or by the intra-abdominal amputation method, as 
already described. 

Complications met during the Operation. — Adhesions may be 
entirely absent with the largest tumors, and, conversely, small 
tumors may present the most firm adhesions to important structures. 
They may attach the growth to any of the pelvic and abdominal 
contents, and are invariably of inflammatory origin. The adhe- 
sions are of two kinds, occurring as longer or shorter bands or as a 
close union between broadly adjacent surfaces. Bands are sparsely 
supplied with blood, but unions by broad attachment are very 
vascular. It occasionally happens that the fibroid will derive its 
main blood-supply from an adventitious adhesion. This is espe- 
cially the case where subserous fibroids are attached to the 
omentum. 

Band-like adhesions not very vascular may be torn with the 



418 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

fingers or by scissors. Those which are vascular must be cut 
between two ligatures. Separation of the adhesions when broad 
must be made at the expense of the tumor, and not of the tissue to 
which it grows. This is pre-eminently the rule when the tumor is 

Fig. 258. 




Suture of the Thin Fold of Peritoneum and Fibrous Tissue left after the Detachment of a Firm Adhesion 
from the intestine : I, intestine ; P, peritoneal fold covering the fibroid ; S, suture. 

closely adherent to the gut. Adhesions are most general and firm 
when there have been former attacks of peritonitis. 

Very commonly hypertrophic salpingitis and chronic oophoritis 
are associated with fibroid tumors. But inflammatory lesions of 
tubes and ovaries are generally due to a septic or specific endome- 
tritis. As frequently producing such changes in the endometrium 
are the various means applied for the relief of hemorrhage and 
attempts at reduction of the tumor. Such are filthy curettements 
and injections of astringents. In other words, here more than 
in the uterus, not the seat of neoplasm, do we find improper 
intra-uterine manipulations one of the causes of complications in 
the adnexa or peritoneum. Milder degrees of tubal inflammation 
may result in occlusion only, thus producing hydrosalpinx. 

It must not be forgotten that fibroid may exist eoincidently with 
ovarian cystoma. Pus-tubes or ovaries should, if possible, be 
removed before the extirpation is begun, and the greatest care must 
be exercised not to permit the escape of any pus to soil the pelvic 
cavity. But cases do occur where the extirpation must first be 
made, the pus-focus being tied off from the tumor and enucleated 
as a last step. 

In such cases the gauze packing must extend to the denuded sur- 
face produced by the removal of the pus-focus. 

General Considerations. — The treatment to be selected for 
each case must not be determined by the character of the tumor 




Fig. 5. 



Fig. 4— Total Abdominal Hysterectomy : vaginal vault in process of closure, with lower stumps 
drawn into the vagina. Opening in the left broad ligament closed. 

Fig. 5.— Total Abdominal Hysterectomy: stump drawn into the vagina, and vaginal opening 
packed with gauze. 



BENIGN UTERINE NEOPLASMS. 419 

alone. Other considerations are to be entertained before arriving 
at the final conclusion. A patient who is in easy circumstances, 
who can afford idleness, and can secure comforts may well spare a 
few months of her life devoted solely to the effort of getting well by 
palliative and mild methods. The poor woman, a burden to her 
friends and unable even to secure necessary physical rest, will de- 
mand a measure which is radical. The general physical condition 
of a patient will determine the character of the operation more than 
any other one thing. An exsanguinated woman who is in good 
flesh will usually stand a long operation very well. Prolonged nar- 
cosis is dangerous if there be kidney or heart disease. Therefore it 
may be that many of the radical procedures would waste valuable 
time, and the most rapid method must be employed, even though it 
be incomplete. In skilful hands it does not take longer to extirpate 
the entire uterus than to properly attend to the stump by the vari- 
ous other methods. Some of the other methods have limitations, 
and there are certain tumors not amenable to each operation. Supra- 
pubic extra-peritoneal amputation is not to be applied to virgins 
who have very short vaginae, to fibroids which dissect into the broad 
ligaments, to those which burrow into the floor of the pelvis, and to 
those which already are septic. 

Hegar's or Tait's operation of removal of the adnexa to induce arti- 
ficial menopause and cut off part of the blood-supply has produced 
results which command our most careful attention. That it will 
check the growth of some tumors, and often cause them ultimately 
to disappear, is undoubted. But it is not immediate in its effect on 
the size of the growth, though the hemorrhages may cease at once. 
Therefore those tumors which have dangerous or very painful pres- 
sure effects demand a more radical procedure. It is hard to say just 
when the operation should be applied to the exclusion of all others, 
for tumors which respond most readily to this treatment also give 
the best results from a radical operation. Certain interstitial and 
subserous tumors require the greatest skill in their removal. In 
certain rare cases of intraligamentous growths, and in patients who 
will not bear a radical operation, we would suggest the sal pin go- 
oophoreetomy. Tumors of the soft, (edematous, fibro-cystic variety 
are but little, if at all, influenced by this operation. It is, then, 
limited to cases of hard myo-fibromata, and chiefly to those in 
women under thirty-five. It must undoubtedly be considered an 
incomplete operation with a limited application, for the natural meno- 



4-20 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

pause does not often come on in the presence of fibroid. In fact, 
the latter continues the bleedings indefinitely. Removing the 
ovaries and tubes, then, very often utterly fails in stopping the 
bleedings, for the operation merely removes the least factor in the 
causation of the hemorrhage, the adnexa. It does limit the bleed- 
ing somewhat in all cases by cutting off the blood-supply through 
the two ovarian arteries, and removal of the adnexa takes away the 
stimulus to menstruation. But the perverted and pathological func- 
tion has usually gone too far to be controlled by such mild means. 
There are very many cases in which the operation is so difficult as 
to be practically impossible. It can only be recommended in an 
extremely limited number of picked cases. 

In his last work Tait quotes 262 cases with 4 deaths — 1.5 per 
cent, mortality, about that incident to the electrical treatment, with 
vastly less suffering, much better results, and less injury to the 
woman in case the operation fails and a radical one becomes 
necessary. But these figures are for uncomplicated cases of fibro- 
myoma. 

We would, then, summarize the treatment of fibroids about as 
follows : Small fibroids which can readily be removed per vaginam 
may be subjected to that method. All others demand different pro- 
cedures. 

The patient's general condition and the character of the tumor 
would determine whether or not to operate. Cases in which the de- 
cision is against operation should be treated by ergot and ammonia. 

An operation deemed advisable, total extirpation is indicated. 
The intra-abdominal amputation method is equally as good, it being 
in all essential respects a total extirpation, provided there is abso- 
lutely no possibility of malignant or tubercular disease being pres- 
ent. This operation has the advantage of being less dangerous than 
that of total extirpation. 

The intra-abdominal methods of Zweifel and Schroeder are no 
longer necessary. The great leap has been from the extra-perito- 
neal operation to the intra-abdominal methods; and at the same 
time we leave a partial operation with a tedious convalescence, adhe- 
sions about the stump, and possibly hernia, for a complete operation, 
with a mortality less than 5 per cent, in the worst kind of cases, and 
no disagreeable sequela?. In selected cases which have escaped elec- 
tricity and other intra-uterine treatment the mortality should not be 
more than 3 per cent. 



PLATE XXVI. 
















I 








Intraligamentous Fibroid Tumor of the Uterus with Hydrosalpinx, showing the portions of the tumor 
which were buried under the peritoneum in the connective tissue : front and back views. 



PELVIC INFLAMMATION. 



It is intended to include under this heading all those inflamma- 
tory pelvic diseases which involve the Fallopian tubes, the ovaries, 
the pelvic peritoneum, and the pelvic cellular tissue — all those con- 
ditions described by the terms salpingitis, pyosalpinx, ovarian 
abscess, perimetritis, parametritis, peri-uterine phlegmon, pelvic 
abscess, pelvic cellulitis, pelvic peritonitis. These conditions are 
so intimately associated and so constantly complicate each other that 
it becomes impossible to treat of one without taking into consider- 
ation several or more of the others. Rarely does a pyosalpinx 
exist except it be complicated by a pelvic peritonitis, and in all 
probability a pelvic cellulitis, the peritonitis and cellulitis arising 
from the same source as the salpingitis, and not being independent 
lesions. The abscesses, for the most part, are results of the more 
advanced stages of these same conditions, and in themselves rarely 
exist as independent factors. It is hard to study these inflammatory 
productions without seeing a direct line of cause and effect. With 
our present knowledge of these matters it is no difficult thing to 
trace the infection from its inception, and to recognize its course in 
the lesions left behind as it pursues its destructive way. 

It is our purpose, then, to deal with this subject as though treating 
a single disease — which in fact and in truth it is — and with each of 
the resultant factors as simply the same disease attacking, in its prog- 
ress, the different anatomical portions of the female pelvis, leaving 
in each locality an apparently different and independent lesion, the 
lesions differing in accordance with the structure attacked, with the 
severity of the attack, and with the stage at which the progress of 
the disease has been stayed. It were just as rational to consider the. 
peritonitis, the cellulitis, and the abscesses complicating an appendi- 
citis as independent of the inflammation of the appendix as to sep- 
arate these same conditions from the salpingitis. In the case of the 
appendicitis the infection comes from inside the appendix, and, 



422 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

having passed through its walls, attacks first the peritoneum, and 
secondly the cellular tissue. 

In the same manner does the infection which destroys the pelvis 
come from the Fallopian tube, only, instead of being compelled to 
pass through the walls of this organ, it the more readily finds its 
way through the fimbriated opening directly into the peritoneal 
cavity and secondarily into the connective tissue. The amount of 
destruction accomplished will of course be in direct relation to the 
severity of the infection. Some attacks will not proceed further 
than the Fallopian tube itself, and often even end there without sup- 
puration. The inflammatory process may extend into the peritoneal 
cavity and confine its ravages to the peritoneum itself, or it may 
extend deep enough to involve the cellular tissue, causing this to 
break down and suppurate. The reason these differences exist in 
individual cases is only to be explained by the character of the 
infection and its virulence. At times two given cases will not 
progress in exactly the same manner, even where the origin has 
been the same. Some local condition may exist so as materially to 
modify the course of the disease in the one case, while the other one 
may proceed rapidly to an amount of destruction which can never 
be repaired, if not unto death itself. When it is fully realized that 
this whole group of diseases originates from a common point and 
from a limited variety of infections, the importance of a careful 
study and understanding of these becomes at once apparent. 

Inflammations of the female pelvis and pelvic organs constitute 
a very large proportion of the diseases of women. They are the 
most destructive and dangerous, as well as the most incurable, cases 
that the physician has to treat, provided they once gain headway or 
have accomplished their ravages before they come under observation. 
At the same time, taken in their incipiency, they are readily retarded 
and cured. As in all other conditions, where it can be accomplished, 
it is much easier to prevent the subsequent ravages of the inflam- 
mation than to cure the resultant lesions. As a rule, after the fire 
has once swept over its course such destruction has resulted that a 
cure short of surgical methods is out of the question, and at times 
even these are unavailing. Once allow a woman to contract pelvic 
inflammation with all its possibilities, and allow the disease to run 
into a chronic condition, the chances are that she will have acquired 
such a degree of invalidism as to feel the results for the rest of her 
life, even though the disease be removed. Many of these women 



PELVIC INFLAMMATION. 423 

never, under the most favorable circumstances, regain their former 
state of health. 

Causation. — Pelvic inflammations arise almost without excep- 
tion from either septic or specific infection. The exceptions are 
those rare cases in which the disease lias had its origin in a sudden 
suppression of menstruation or where it is due to the irritation of 
neoplasms, such as fibroid tumors and ovarian cysts. Even in these 
exceptions it becomes a question at times whether or not the peri- 
tonitis, be it acute, has not originated from septic material contained 
in a diseased Fallopian tube or ovary. Chronic inflammation may 
readily be engendered by the irritation due to the presence of an 
abnormal growth in the pelvic cavity, but such a process seldom 
brings about such disastrous results as do the acute inflammatory 
attacks. The changes here are more of a gradual thickening and 
hypertrophy of the epithelial and interstitial elements, and there is 
little or no danger of resultant adhesions or abscesses. A very 
great many neoplasms are complicated by disease of the Fallopian 
tube. It is obvious what chances there are of a leakage of infective 
material from an enlarged and diseased tube. Even where there is 
no leakage through the fimbriated end, or no rupture of the walls 
of the organ, yet it is a well-known fact that the peritoneum about 
these members is peculiarly liable to attacks of inflammation, prob- 
ably by extension of the disease directly through their walls. Any 
given case of pelvic inflammation complicating the growth of a 
neoplasm is always open to the just suspicion that there is, in addi- 
tion to the new growth, a lurking infection in the Fallopian tube. 
In such a case the cause of the inflammation would again be sought 
in a septic or specific poison, brought about in much the same man- 
ner as are the vast majority of cases of pelvic inflammation. It is 
well known that the rupture of some cystic tumor, and the empty- 
ing of part or all of its contents into the abdomen, may give rise to 
this same character of trouble. These cases are, however, the excep- 
tion, and usually, when they do occur, it is not difficult to differentiate 
them. Those cases which are apparently due to the traumatism inci- 
dent to operations, the use of the uterine sound, the introduction of 
sponge tents, and other similar procedures are beyond doubt caused 
by the addition of septic poison to the traumatisms, and not to the 
mere wounds themselves. Careful use of ordinary antiseptic precau- 
tions will obviate any chance of such mishaps. If a patient is 
suffering from venereal disease, and a solution of continuity of the 



424 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

mucous membrane, either of the vagina or uterus, is made in the 
course of an operation or an examination, it is hardly to be expected 
that there will be a universal escape from some of the disasters of 
a spread of the infection into the connective tissues through the 
open wounds so made. 

If, however, the disease be cured prior to an attempt at operative 
procedures, or even if great care has been taken to disinfect the 
parts to be operated upon, the chances of infection are minimized. 
The same may be said of infection carried by dirty instruments 
during the course of an examination. It is extremely problematic 
whether or not many cases have resulted from such sources where 
even the most ordinary care has been taken with the implements 
used. A speculum or a pair of dressing forceps must be noticeably 
dirty to carry infection from one patient to another, particularly 
if the mucous membrane of the vagina is reasonably sound and 
healthy. The danger resulting from the use of a sponge tent is 
likewise due to a septic condition of the tent or of the vaginal or 
uterine canals ; and so with most other instruments usually held 
accountable for the origin of pelvic inflammations. 

As in the case of neoplasms, so in all cases that require the use of 
instruments, it is far more likely that there is already existing the 
source, of infection in the Fallopian tubes, ovaries, or peritoneum than 
that the use of these instruments has originated the attack. If a 
woman has a diseased and possibly adherent Fallopian tube, espe- 
cially if it be distended with pus, any manipulative interference will 
surely tend to relight an inflammation which has become quiescent, 
and has probably remained so for years. If the disease be originated 
by the mere use of the instrument, it is almost certainly not due to 
the introduction of septic or specific poison as an additional element 
in the case. It is problematic whether traumatism per se ever orig- 
inates pelvic inflammation. The peritonitis due to sudden suppres- 
sion of menstruation does not, as a rule, leave behind it any such 
traces as are left after an attack of septic peritonitis. The inflam- 
mation is of a frank, open character, without usually any tendencies 
to the exudation of plastic lymph, such as will not subsequently be 
absorbed. When such an attack has cleared up, there are left no 
microscopic lesions, except it be in the ovary itself, and here the 
changes are more likely to be of an interstitial character, such as 
follow chronic inflammation in these organs. Frequently these 
attacks do not amount to anything more than a severe congestion, 



PELVIC INFLAMMATION. 425 

stopping short of true inflammation, rest in bed and depletion 
accomplishing a speedy and permanent cure. Pelvic peritonitis 
caused by venereal excess, independent of any other factor, is more 
than doubtful. The traumatism, it is true, incident to such excess 
would tend to foster such a result, but the continued relief from 
congestion due to the repeated normal terminations of coition would 
tend to promote anemia of the parts rather than congestion. As in 
the case of many other supposed causes, a previously diseased condi- 
tion of the uterus or uterine appendages is in all probability at the 
bottom of the trouble, in which case it is easy to understand how the 
incidental and repeated traumatism would bring about the result. 

Septic or specific infection of the genital canal is the cause of the 
vast majority of pelvic inflammations. Septic infection enters in 
one of two ways : either through wounds caused by operations 
(the use of tents, the use of the uterine sounds, specula, and other 
instruments) or through the wounds caused by childbearing and 
abortion. 

Puerperal septicemia outweighs by far all the other sources of 
septic trouble, and compared with this source the others are practi- 
cally nil. Puerperal septicemia rivals, and even exceeds, gonorrhea 
as an etiological factor in these diseases. The analysis made by Ber- 
uutz of 99 cases of pelvic peritonitis shows at a glance the two great 
factors in the production of pelvic inflammatory troubles : 

43 occurred in puerperae ; 

28 " after gonorrhea ; 

20 " during menstruation. 

3 due to venereal excess ; 
2 " syphilitic disease of the cervix ; 
| 2 " introduction of the uterine sound ; 
ll " use of the vaginal douche. 

This table is susceptible of considerable modification, and if the 
whole truth were known it is more than probable that every 
case in it could have been traced to gonorrhea or post-puerperal 
septicemia had as much been known of these troubles in the 
time when the cases were tabulated as is known about them at 
the present time. It is more than probable that in every one of 
the 8 traumatic cases and in the 20 recorded as occurring during 
menstruation, there was present in the pelvis a pre-existing inflamma- 
tory disease which was only awaiting some favorable opportunity to 



426 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

develop. That twenty of the attacks took place during the men- 
strual period is only what could be expected. At this time there is 
a natural congestion of the pelvic organs ; this congestion, added to 
the already existing inflammation, latent perhaps, but none the less 
real, would place the patient in the best possible condition for any 
outside influence to determine the resulting acute attack of pelvic 
inflammation. Forty-three of the cases are recorded as occurring 
in puerperse, and twenty-eight after gonorrhea. A second glance 
is convincing that in all probability a few of the puerperal cases 
were caused by gonorrheal infection — just what proportion it is 
impossible to tell. The argument might, in fact, be brought to 
bear in every case of post-puerperal septicemia, that the woman had 
previously been infected with gonorrhea, else she would not have 
developed the puerperal disease. Such is undoubtedly the case in 
many instances, but, in spite of the great possibility of such an 
occurrence, there is yet a large proportion of cases which undoubt- 
edly arise from a puerperal septicemia, entirely independent of 
venereal contamination; the proportion is fully as large as in 
that class where the cause is unquestionably gonorrhea. This 
is even true of many of those women whose husbands have per- 
chance contracted a gonorrhea in their younger days before 
marriage. Because a man has once been afflicted with venereal 
contamination, it by no means follows that he always retains the 
disease, as has been contended by some writers, nor that he is sure 
to contaminate any woman with whom he has intercourse. Whether 
or not the gonococcus is the cause of gonorrhea, it is notorious that 
many discharges contain this factor without being able to reproduce 
the disease. It has been shown, also, that it is not possible to infect 
the healthy mucous membranes with the discharges from some cases 
of chronic gleet. On the other hand, experiments have been j)ro- 
duced to show that quite the reverse of this is true. However this 
may be from an experimental point of view, certainly the relation 
of cause and effect in such a case as the following is apparent: 
A young and healthy woman is married to a man who some 
time previous to their marriage had contracted gonorrhea, but of 
which he was cured before the ceremony. She bears one, two, or 
three children successively, always making a satisfactory recovery 
and remaining in robust health. Following a third or fourth preg- 
nancy she develops puerperal septicemia, and is ever afterward a 
sufferer. It can hardly be contended in such a case that gonorrhea 



PELVIC INFLAMMATION. 427 

played a very important role in the production of the septicemia. 
Large numbers of women suffering from pelvic inflammatory dis- 
eases give practically the same history as this, less the fact that the 
husband had pre-existing venereal infection. 

Generally, when a woman contracts gonorrhea the first step is 
the production of a vaginitis. As it is but a short distance from 
the vagina to the uterus, this is usually quickly traversed. Occa- 
sionally there is no vaginitis noticeable, the first lesion being an 
endometritis. The uterus, in case the infection is of puerperal 
origin, is the original seat of the attack. Whether or not the 
disease starts or exists elsewhere, an endometritis eventually de- 
velops in every case of gonorrheal or puerperal pelvic inflammation. 
This fact is important to bear in mind when it comes to the treat- 
ment of the disease, both as to prophylactic measures and as to the 
final cure, even though surgical treatment has been necessitated 
and carried out. Practically, the mucous membranes of the uterus 
and the Fallopian tubes are one and the same, the anatomical differ- 
ences not amounting to more than a change in the character of the 
epithelium. 

The disease has one unbroken line of membrane over which to 
extend and reach the peritoneal cavity, and it is only a matter of 
surprise that it ever confines itself to the lining membrane of the 
uterus. That it does so in many cases is, however, beyond dispute. 
If the infection be confined to the uterine body, the dangers of 
a peritonitis are very small, as the chances of the poison being 
carried through the uterine walls by way of the lymphatics are not 
great. The extension is nearly always by way of the Fallopian 
tubes, the exceptions to this being found amongst the puerperal 
cases ; and even here an example is met infrequently. In such 
cases we would naturally expect the cellular tissue about the uterus 
to first become affected and to undergo suppuration. As a matter 
of fact, such conditions exist only occasionally, the cellulitis being 
almost universally secondary to the inflammation of the peritoneum. 

One of the many proofs that the infection has proceeded directly 
from the tube itself, and not from the uterus by way of the lym- 
phatics, is that it is rare to find traces of inflammation in the shape 
of adhesions on the anterior surface of the broad ligament, between 
this structure and the bladder. The evidences of the infection are 
almost universally found on its posterior surface, between the lig- 
ament and the sacrum. This would seem to be accounted for by 



428 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

the anatomical position of the tube and ovary on the posterior sur- 
face of the broad ligament. 

The more virulent the infection and the more rapidly it extends, 
the greater will be the chance of its reaching the peritoneal cavity 
through .the open fimbriated end of the Fallopian tube; the greater, 
in consequence, will be the destruction to the various organs, and 
the more will be the chance of a fatal termination. 

As the infection extends from the uterus, it spreads at once along 
the mucous membrane of the Fallopian tube, out of its fimbriated 
opening directly to the ovary and into the pelvic peritoneum. 

Pathological Anatomy. — The inflammation engendered by the 
infection, whatever it may be, is in all respects the same whether 
confined to the Fallopian tube, the ovary, a part or the whole of 
the pelvic peritoneum and cellular tissue, or to the whole abdom- 
inal cavity. It is simply a question of anatomical limitation, 
the extent of limitation being determined by the character of the 
infection, its virulence, and the ability of Nature to quickly meet 
and confine it within a limited space. Usually, Nature is capable 
of meeting the invasion more than halfway, and she not infrequently 
shuts off the most important avenue of approach to the pelvic cavity 
by firmly sealing the fimbriated opening of the tube. If she be 
successful in accomplishing this, there is no very great danger that 
the inflammation will pass through the walls of the tube, and thus 
infect the pelvic cavity to more than a limited extent. The possi- 
bility of this must be borne in mind, as undoubtedly the inflam- 
mation has spread in this manner, but only, however, in particularly 
virulent cases. Such instances are the exception rather than the 
rule. 

Whatever be the source or cause of infection, the results are the 
same up to a certain point, as in all inflammations. The moment 
the tissues are involved, there occurs first a congestion, followed 
rapidly by effusion. Resolution may or may not follow later in the 
progress of the case ; the rule is that it takes place to a greater or 
lesser degree. If resolution does not occur, either organization or 
suppuration is the final step. Whether the inflammation be a super- 
ficial one, involving only the mucous membranes of the Fallopian 
tube or the serous membrane of the pelvic cavity, or whether it 
will extend into the deeper structures of these parts, will depend in 
great measure on the virulence of the attack and its rapidity of 
advance. For the most part, the disease invades, to a greater or 



PELVIC INFLAMMATION. 429 

lesser extent, the connective tissues : as a matter of actual fact, few 
cases of salpingitis and peritonitis exist without some involvement 
of the deeper and looser tissues. The exudation occurs in two 
places : on the surface of the membrane and in the underlying 
connective tissue. In the Fallopian tube the mucous membrane 
excretes serum which collects and dilates the tube-cavity. This 
fluid is liable to either discharge itself into the uterine cavity 
through the uterine opening of the tube, or into the pelvic cavity 
through the fimbriated opening, or it may be retained and accumu- 
lated in consequence of boih these openings becoming closed by the 
inflammatory process. Whether retained or not, it is extremely 
liable to undergo suppurative changes and terminate in pus-form- 
ation. Should this material empty itself into the uterus, it will drain 
into the vagina, and will eventually be disposed of in a comparatively 
harmless way. If it remains encysted in the Fallopian tube, we will 
have formed either a hydrosalpinx or a pyosalpinx ; more usually the 
latter. The amount poured out is variable, depending upon the 
irritating properties of the infection. Should it discharge itself into 
the pelvic cavity, whether it has undergone suppurative changes or 
not, it is liable to set up an inflammatory condition of the pelvic 
peritoneum, even though this membrane is not already involved. 
The exudation into the connective tissue varies also in degree and 
kind. The greater the exudation and infiltration of inflammatory 
cells, the thicker and denser become the tube-walls. So thoroughly, 
in fact, may the walls be penetrated by the inflammation that the 
peritoneum covering them may become involved. The infiltration 
may subsequently become absorbed; it may remain and undergo 
partial organization or it may take on suppurative changes. Fre- 
quently, when to the naked eye a Fallopian tube appears to be per- 
fectly free from suppuration, the microscope will show indubitable 
evidence of the infiltration of pus-corpuscles into its walls. This 
may, and does, frequently extend to the degree of rendering all the 
involved tissues so thoroughly friable as to cause them to break 
down under slight manipulation or under the pressure of a ligature. 
A. ligature will at times cut through such tissue like a knife, the 
blood-vessels alone offering any great resistance, and even these 
give way in many instances. It is not at all unique to see the sup- 
purative process extend so far that pus may readily be extruded 
from the cut surfaces of the walls of the thickened and diseased 
tube. Should the infiltrating products of the inflammation not be 



430 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

absorbed, they may leave the tube in a permanently thickened and 
hypertrophied condition. There will result in this case an enor- 
mous overgrowth of the connective-tissue elements, with a possible 
permanent infiltration of inflammatory cells. Where the disease 
in the tube has extended to either of the above conditions, the peri- 
toneum will have become sufficiently involved to throw out plastic 
lymph, which will undergo partial organization and form adhesions. 
Should the attack prove a mild one, in all probability the exudation 
will be absorbed and the case progress toward a complete cure. At 
times, where the disease in the uterus is quite severe, it will stop 
short of an inflammation in the tube, and after existing for a time 
as a congestion may gradually disappear altogether. It is no infre- 
quent thing to find at the time of an operation that the uterus is 
badly diseased, and the tube is only, as yet, greatly swollen and 
deeply congested, but without showing any signs of infiltration. 
So also with the peritoneum. A badly crippled tube may exist, the 
fimbriated end becoming closed and adherent to the ovary, with the 
tube-cavity distended by a muco-purulent serum. The serous mem- 
brane may simply be congested, with no excretion of lymph, no 
adhesions, no true inflammation. The removal of the tube with its 
contained source of infection and irritation is amply sufficient to 
put a stop to further advance of the disease : before the patient is 
recovered from the operation all traces of the peritoneal congestion 
will have disappeared. 

Should the inflammauon have spread from the tube to the pelvic 
cavity, either by the extension of the disease from the tube through 
its fimbriated opening or by the subsequent pouring out of the 
excreted tubal serum, which has undergone muco-purulent changes 
or not, or by direct extension through the walls of the tube itself, 
the disease takes on exactly the same form as it would in any other 
serous membrane, differing only in so far as the anatomical features 
differ. The pathology of peritonitis is like that of inflammation of 
other serous membranes — first, congestion, then transudation of blood- 
serum, and, finally, an exudation of plastic material. Should reso- 
lution take place, these inflammatory products are disposed of by 
absorption of the serum and organization of the exudate. Organ- 
ization simply consists in the development of the circulation in the 
exudates sufficient to prevent their degeneration. Should this not 
occur, they usually break down into suppuration. The exudation 



PELVIC INFLAMMATION. 431 

of the serous membranes assumes one of three forms : fibrinous, 
serous, or suppurative. 

In the fibrinous form, should two opposing surfaces touch each 
other, they will almost certainly become adherent until such time 
at least when the lymph becomes absorbed. If it does not finally 
disappear by absorption, permanent adhesions result, more or less 
dense and well organized in accordance with the original amount 
of lymph excreted and the activity of proliferation in the under- 
lying endothelial cells of the serous membrane. The more exten- 
sive the involvement of the peritoneum, the more extensive will be 
the resultant binding together of its various surfaces. Should the 
exudation prove to be of the serous variety, adhesions are much less 
apt to form. Varying quantities of free serum, in a more or less 
changed condition, will be found in the pelvic cavity, and the serous 
surface will most likely be covered with flakes of lymph. The sup- 
purative variety is simply an advanced stage of either of the other 
two. As to whether or not suppuration occurs, depends, again, 
upon the character of the infection. Occasionally the infection is 
so virulent that the case has progressed to a fatal termination before 
suppuration has had time to occur. 

Should the inflammation involve the deeper tissues, as is almost 
always the case, effusion takes place into the cellular tissue. The 
extent to which this will occur is dependent directly upon the activ- 
ity of the advancing inflammatory process. At times the effusion 
is slight in quantity, and causes but little distension of the loose 
areolar tissues ; in other cases so much effusion is thrown out as to 
distend the connective tissues to their fullest extent. The greater 
the amount of effusion, the more hard and board-like will the part 
appear to the touch on a local examination. Should the case prog- 
ress favorably, there will eventually be an absorption of these 
inflammatory products and the parts will return to a condition of 
health. Should anything supervene, on the other hand, to prevent 
Nature from absorbing and disposing of this serum in the ordinary 
way, it becomes denser and apparently makes an effort at organiza- 
tion. If infective germs should reach it from any direction, suppu- 
ration will take place and all hopes of a spontaneous cure will be 
lost, except through a prolonged and extremely hazardous illness. 
The extent of the suppuration does not altogether depend upon the 
extent of the infiltration, for the reason that after this process has 
progressed to the limits of the effusion it very frequently con- 



432 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

tinues on, involving the healthy connective tissue, step by step y 
until eventually it may involve most of the connective tissue of 
the pelvis, and has even been known to discharge at the umbilicus. 

Except in a limited number of puerperal cases, the course and 
termination of a septic or specific inflammation of the uterus are 
as described. The few exceptions to this rule occur, as has been 
said, in puerperal patients. A woman contracts septicemia after 
childbirth or abortion, by having septic germs introduced into the 
uterus. The amount of septic material which will be necessary to 
contaminate a woman under these circumstances will probably be 
such as would have no effect whatever upon a healthy non-gravid 
womb. After the placenta has been removed there is left, to all 
intents and purposes, an open wound, or what would be an open 
wound were it on any of the skin surfaces of the body. 

The incidental wounds due to traumatism add another element 
to the dangers of this variety of infection. The placental wound 
is peculiarly liable to pathological changes, for the reason that it is 
difficult of access and treatment, such as a similar wound elsewhere 
would receive. Again, the torn ends of the hypertrophied vessels 
and other tissues are disposed of by a process of degeneration 
which borders closely upon the pathological — a physiological pro- 
cess which the slightest amount of contamination by septic matter 
will change into a pathological one. Should such a wound once 
become septic, the enormously enlarged lymphatics stand ever 
ready with their gaping mouths to receive and convey into the 
deeper tissues the products of the suppuration. One would imagine, 
with the frequency of the occurrence of puerperal septicemia, that 
this condition would result frequently, when, as a matter of fact, it 
is the exceptional occurrence. If the septic products are taken up 
by the lymphatics, the chances are largely that they will be con- 
veyed into the blood without any particular involvement by the 
inflammatory process of the walls of the lymphatic vessels or of the 
connective tissue binding them together or through which they pass. 
At times, however, some additional element seems to be introduced 
which causes the inflammatory process to rapidly pass along and 
about the walls of the vessels and lymphatics directly into the sur- 
rounding connective tissue, thus conveying the septic material 
primarily into the connective tissue and rendering any peritonitis 
which may follow secondary to the cellulitis. The fact of the exist- 
ence of this class of cases (although of great rarity) does not detract 



PEL VIC INFLA MM A TION. 



433 



from the statement that in the vast majority of cases of pelvic 
inflammation the cellulitis is secondary to the peritonitis, and is 
consequently only of comparative importance. Usually the treat- 
ment directed toward the cure of the peritonitis accomplishes also 
that of the cellulitis. 

Results. — The results left in the train of an inflammation 
beginning in the uterus, extending into the Fallopian tubes, and 
from thence into the pelvic cavity, are widely variable. In the 
tube they extend from a slight salpingitis to a pyosalpinx ; in the 
peritoneal cavity, from a mild attack of local peritonitis to a general 



Fig. 259. 




Normal Fallopian Tube : A, section from the ampulla ; B, section from near the uterus. Layers of the 
Fallopian tube : 1, upper and outermost layer, serous coat; 2, layer of loose connective tissue, richly 
^applied wilh blond- vessels ; '■'; muscular coat, much thicker near the uterus than near the ampulla. 
It is principally made up of circular fibres. Above and within it is reinforced by longitudinal fibres, 
some of which spread into the mucous layer ; others (the most external] penetrate between the layers 
of the bmad ligament: still others go to the hilum of the ovary or are prolonged to the fundus of the 
uterus; a few fibres penetrate to the inner layer. 4, mucous coat. The framework of this layer is 
embryonic connective tissue, rich in fusiform cells: it projects into the lumen of the tube in longi- 
tudinal folds which have been cut through obliquely in the section shown above. Near the uterus 
these folds are radiating, and give a star-shaped appearance to the lumen in the section. Near 
the ampulla they are longer and reduplicated, giving the lumen a jagged or toothed appearance on 
section. The whole surface of the mucous membrane is lined with simple columnar ciliated epithe- 
lium ; the movement of the cilia is in the direction of the uterus. 



suppurative peritonitis and cellulitis ; in the ovaries, from a simple 
ovaritis to an ovarian abscess. In the milder forms of salpingitis 
the disease assumes the catarrhal type. Here the inflammation is 
confined almost, if not entirely, to the mucous membrane lining the 
Fallopian tube, there being oftentimes an accompanying congestion 
of the other constituent parts. The cause of the tubal involvement 
is always resident in the uterus, usually in the shape of an endo- 
metritis, and occurs by direct extension from one mucous membrane 



434 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



to the other, the disease in the tube not always being so severe as 
that in the endometrium. The process exists in both an acute and 
a chronic form. Neither gives rise to any particular symptoms 
other than indirect ones, such as sterility. The acute form may 
run its course rapidly and be cured spontaneously, or may subside 
as the endometritis is relieved. On the other hand, it may continue 
indefinitely, and finally become chronic. During the existence of 
the inflammation, especially in the acute form, an excess of sero- 
mucous products is thrown out. Where there are no adhesions 
found, but the uterine and fimbriated ends of the tube remain patu- 



Fig. 260. 




Lytlrosalpinx. 



lous, these products are drained either into the uterine or pelvic 
cavities. Should their openings become occluded from any cause, 
as is at times the case, the sero-mucus accumulates, distends the 
tube, renders its walls thin, the tube becoming larger and larger as 



PELVIC INFLAMMATION. 435 

the contents increase. The condition is then known as hydro- 
salpinx. The very mild cases seldom terminate in this manner, for 
the reason that there is not sufficient active inflammation to cause 
occlusion of the tubal openings. Where a hydrosalpinx exists, 
it is often found to be adherent to surrounding parts. The fact 
of the presence of a healthy, non-inflammatory tumor of reason- 
able size in the pelvis is not in itself sufficient to account for 




c 






Hydrosalpinx. 



inflammatory processes arising in its peritoneal lining. Either the 
original inflammation, slight as it may be, has spread through the 
walls of the tumor, which have become much thinned, or there has 
been leakage of some of the tube-contents, which are acrid and 
irritating. 

Should the inflammation become a chronic condition, which is 
the more usual procedure, the result is more apt to be a destruc- 
tion of the ciliated epithelium lining the tube, and a consequent 
permanent crippling of that organ for its legitimate functions. 
The desquamation of the epithelium is also claimed to be a sequel 
of the exanthematous disease. To how great an extent this is true 
is uncertain. There is not the slightest reason why this mucous 
membrane should be more affected than that of other parts of the 
body. Where there has been a general and undoubted involvement 
of all the mucous tissues in the body there is no reason to expect 
that this particular one has escaped. Otherwise, the cause and 



436 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

effect of these diseases are extremely problematic. It is this de- 
squamation of the ciliated epithelium in the catarrhal salpingitis 
that is in great measure responsible for a large proportion of cases 
of sterility and extra- uterine pregnancy. The normal function of 
the ciliated epithelium is to carry all the tube-contents toward the 
uterus. If in consequence of its destruction the ovum is retarded 
in its progress until the spermatozoid is too enfeebled to perform its 
function, or if the ovum simply lodges in the tube and there loses 
its vitality, sterility must of necessity follow. Again, if the dis- 
charges from the altered and diseased mucous membrane are acrid 
and acid, neither the ovum nor the spermatozoid can survive, or at 
least they are so enfeebled when they meet that they fail to unite, 
or if they unite, fail to accomplish their destiny. Should the calibre 
of the tube be closed at any point throughout its extent, of course 
an insurmountable mechanical obstruction exists which it is impos- 
sible for either element to overcome. If the male and female ele- 
ments should meet in the tube and the ovum become fecundated, the 
product of conception is very apt to lodge at some point along the 
course of the tube and continue its development. 

Occasionally the inflammation of the tubal membrane assumes 
the hemorrhagic type and the excretions are mingled with blood. 
Provided these muco-bloody discharges empty themselves into the 
uterus, there will be no more difference in the result than if the 
excretion were merely mucous or serous. If adhesions close the 
ends of the tube, it becomes distended with the contained fluid, as 
in hydrosalpinx, and is then known as hematosalpinx. This 
occurrence is infrequent as compared with the formation of hydro- 
salpinx. 

When the infection is more severe and extends into the Fallopian 
tube from the endometrium, involving almost simultaneously all the 
layers of the tubal wall, the resultant condition is more important 
as well as more dangerous. Exudation takes place into all the coats 
of the tube, and the inflammation extends even to the peritoneum. 
The openings into the tube may become closed or may remain pat- 
ulous; usually they are occluded. The inflammatory products in 
the walls of the tubes increase. The walls vary in thickness in 
accordance with the amount of infiltration, in particularly bad cases 
being from a quarter to half an inch thick. Attempted organiza- 
tion may take place, the result being the production of an over- 
growth of the connective-tissue elements, giving the tube a greater 



PELVIC INFLAMMATION. 437 

or lesser consistency. The products of inflammation thrown out by 
the mucous surfaces are either discharged through the tubal open- 
ings or, if the openings are not patulous, are absorbed. The inflam- 
matory products thrown out on the peritoneal covering of the tube 
assume the form of plastic lymph, and cause the tube to adhere to 
any other peritoneal surface it may touch. The tube itself adheres 
commonly to the uterus, broad ligament, and ovary : the fimbriated 
end usually grasps the ovary tightly, and the fimbria themselves 
may become destroyed by the disease. 

This condition presents the disease known as chronic (adherent 
or interstitial) salpingitis. It must be borne in mind that this con- 
dition is distinctly different from those forms of pure chronic ca- 




Chronic Interstitial Salpingitis and Ovaritis, with thickened broad ligament— so-called cellulitis. 

tarrhal salpingitis in which the inflammation affects only the 
mucous lining of the tube, and results simply in a permanent alter- 
ation of that membrane, without particularly affecting the walls of 
the tube or its investing peritoneal covering. 

Chronic interstitial salpingitis is nothing more or less than the 
mildest form of the same condition, which frequently progresses to 
the development of a pyosalpinx. If there be good drainage of 
the tube, there is not much danger of muco-purulent material 
accumulating. There may, it is true, be a certain amount of 
suppuration taking place, even the walls of the tube becoming 
involved. The result under these circumstances would be in accord- 



438 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

ance with the patency of the tubal canal. If the canal remains 
patulous, the only additional harm will be the breaking down of 
the inflammatory products infiltrating the walls, and the consequent 
rendering of these friable, if they do not actually suppurate. This 

Fig. 263. 




Fallopian Tube and Ovary, showing adhesions. 

same process may extend into the lymph thrown out by the 
peritoneum, and cause the adhesions to become friable or even 
to suppurate. 

Should suppuration occur, inflammatory products within the 
tube may drain away into the uterus, and the suppurative process 
finally cease, leaving the tube in its crippled adherent condition. 
The uterine opening will remain patulous long after the fimbriated 
opening is closed and the fimbria destroyed, for the reason that the 
peritoneum is much more delicate than the endometrium, and the 
irritation of the advancing suppuration will early cause it to throw 
out protective lymph, which will effectually seal the opening and 
protect the peritoneal cavity. The suppurative process may keep 
up indefinitely, the tube constantly discharging its muco-purulent 
contents into the uterine cavity and thence into the vagina. This 
is of no infrequent occurrence. The uterine opening may even 
become closed by light friable adhesions, the tube distend with its 
suppurative contents, until either the pressure of the over-disten- 
sion causes the adhesions to give way or they break down from 
suppurative changes, the result in either case being a periodical 
discharge of pus from the tubes. The tubal openings usually 
become permanently closed by adhesions. If the tubal contents 
are small in quantity, they may eventually become absorbed ; but 
this cannot be a common termination. It is not of infrequent 
occurrence to find the Fallopian tube distended with a broken- 
down, cheesy material. In these cases the watery elements of 



PELVIC INFLAMMATION. 



439 



the pus have been absorbed, and the solid portions have under- 
gone a caseous degeneration. Such conditions are very apt to be 
due to tubercular changes. Were the constituent tissues of the 
tube healthy, there would be more probability of complete absorp- 
tion. In the cases under consideration all the parts of the tube are 
so diseased and disorganized that their functions are for the most 
part suspended. However, certain cases are met with clinically in 
which no other interpretation is possible, and it may be put down 
as one of the probabilities. 

When the contents are not absorbed, a true pyosalpinx results. 
The tube becomes distended with a greater or lesser quantity of pus 




Double Pyosalpinx and Diseased Uterus, removed by Supravaginal Hysterectomy. 



or muco-purulent matter. In such cases the inflammatory infil- 
trates in the tube-walls have most probably shared in the suppu- 
rative changes, rendering the walls soft and cheesy ; the microscope 
will show them filled with pus-corpuscles. The peritoneal serum 
and lymph do not escape the suppurative changes. The pus may 
have worked its way directly through the tube-wall, and then 
infected the lymph, or the infection may have passed through the 
fimbriated opening of the tube, and in this manner contaminated 
the peritoneal elements. Small abscesses frequently result, in con- 



440 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



sequence, in the midst of the adhesions, and on removal of the tube 
by abdominal section these abscesses, which are as often as not 
multiple, are opened, their contents soiling the field of operation. 
If the pus has passed directly through the tube-wall, these small 




Pyosalpinx and Ovar 



local abscesses will probably be the worst result. Should the infec- 
tion pass out through the fimbriated opening, however, it may 
spread rapidly to the whole pelvic or abdominal cavity, and end in 
a general suppurative peritonitis. The reason of this difference is 
that when the suppuration extends through the tube-walls it never 
enters the general peritoneal cavity, but always meets the obstructing 
lymph which the peritoneum has had plenty of opportunity to 
throw out about the threatened point. This same obstruction is 
most always met with at the fimbriated opening, in which case the 
result is the same ; but occasionally the infection itself travels 
along the tubal mucous membrane so quickly that it has time to 
escape before it can be closed in by the peritoneal lymph. 

When the infection has once passed beyond the fimbriated open- 
ing of the Fallopian tube, it attacks either the ovary, the pelvic 
peritoneum, or both. Should it confine itself to the peritoneal 
investment of the ovary, it causes excretion of lymph, which binds 
that organ to the tube. The fimbriated end of the tube becomes 



PELVIC INFLAMMATION. 441 

firmly attached to the ovary, not infrequently an abscess developing 
at the point of junction, which is known as a tubo-ovarian abscess. 
Should the infection penetrate the outer coat of the ovary or infect 
a ruptured Graafian follicle, there will begin and form in the ovarian 
stroma an abscess which may eventually reach even the size of an 
orange. Such an ovary is, as a matter of necessity, on account of 
the involvement of its peritoneal covering, densely adherent to all 
peritoneal surfaces which come in contact with it. Where there is 
no infection, but where the inflammation spreads from the tube and 
involves the ovary, this organ takes on changes of an interstitial 
character, which eventually cause such a destruction that there is 
little left of the healthy ovarian stroma. At times these organs 
assume much the character and appearance of hypertrophic scirrhosis ; 
at others, an atrophic condition. In either case the function of the 
organ is much changed, even destroyed, and the ovary is most 
likely to give rise to very distressing symptoms. 

The infection may pass along the Fallopian tube and infect the 
ovary, even to the extent of forming an ovarian abscess, without 
leaving behind more than a catarrhal condition in the tube. When 
the infection invades the peritoneum, it remains often a local affec- 
tion, but in a reasonably large proportion of cases spreads until 
it invades more or less the whole of the pelvic peritoneum. It 
may, in fact, continue and develop into a general abdominal 
peritonitis. In attacking the peritoneum any one of these forms 
of peritonitis are likely to develop : the fibrinous, the serous, or the 
suppurative. The fibrinous variety is by far the most frequent 
form accompanying inflammatory diseases of the Fallopian tubes 
and the ovaries. The serous variety is most likely to be of the 
nature of that peritonitis which so often follows the performance 
of a cceliotomy ; it runs its course usually in three or four days, and 
most generally ends fatally. It may, as a matter of fact, occur 
under any source of infection. The lesions in such a case, on 
examination, will be found to be universal but light adhesions 
between all the coils of intestines located in the pelvic cavity, as 
well as of all the pelvic contents. After the various organs are 
separated a few ounces of bloody serum will be found in the pelvic 
basin, and the peritoneal surfaces will be observed to be covered 
with flakes of lymph. The process has been too rapid for the 
formation of pus in many instances, and as a rule there is not 
a great deal of involvement of underlying connective tissue. The 



442 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

fibrinous variety is the common one. The irritated and inflamed 
serous membrane begins at once to develop that great protector, 
lymph. This material precedes the infection, and, unless the 
advancing inflammation is too rapid, bounds it within certain limits. 
Frequently it confines the inflammation to the serous covering of 
the tube itself. The inflammation may have advanced further and 
involved the serous covering of the ovary and the broad ligament. 

As the inflammation advances step by step it is continually met 
by the obstructing plastic material which the threatened and irri- 
tated peritoneum is throwing out for its protection, until, having 
spent its forces, it makes less and less effort at advance, and finally 
settles down within the limits into which the lymph has been able 
to confine it. 

The extent of the destruction will have depended much upon 
the rapidity of the advance and the virulence of the infection. 
The lymph may have succeeded in confining it to the immediate 
neighborhood of the diseased Fallopian tube and ovary, or the 
inflammation may have spread to the whole of the pelvis, or in 
extreme cases to the general abdominal cavity. The inflamed 
peritoneal surfaces, wherever they come in contact, become glued 
together by the lymph. By the time the inflammatory forces 
have spent themselves, the serous membrane is infiltrated with the 
inflammatory products, resulting in its becoming thickened as well 
as being covered with lymph. 

Should the case terminate in the most favorable manner, all the 
lymph and other inflammatory products would become partially ab- 
sorbed, and the other parts return once more to a comparative con- 
dition of health. It is at this point that electricity has gained its 
greatest reputation. The lymph exists in considerable masses, and, 
as Nature begins to get rid of this accumulation, electricity comes in 
as an extra spur to hurry Nature's work. The result is in many 
cases a quicker absorption and an apparent cure, the facts being 
that the gross amount of lymph has disappeared, but the disor- 
ganized and adherent appendage remains, ready to relight the 
original inflammation upon the slightest provocation. 

The fact is notorious that these chronic conditions are liable to 
repeated recurrent acute exacerbations of inflammation. 

The more usual result, however, of such an inflammation of the 
pelvic peritoneum spreading from the Fallopian tube is to cause a 
broken-down and destroyed tube and ovary; both become enlarged, 



PLATE XXVII. 




Pyosalpinx and Ovarian Abscess, showing the remnants of universal adhesions. 



PELVIC INFLAMMATION. 



443 



heavy, prolapsed, and adherent to each other, the broad ligament,, 
the uterus, and the pelvic walls. One step further, and the superim- 
posed intestines and omentum are involved, and become adherent 
on top of the diseased and adherent pelvic organs. At times there 
is no pus complicating the general destruction ; at others pus is 
found in the Fallopian tubes, the ovaries, in the midst of the adhe- 
sions in which these organs are imbedded, or filling the whole pel- 
vis. The Fallopian tubes themselves are so distorted that numerous 
separate pockets of pus are found in a single tube. As many as 
three such collections have been found in the same tube, each of 




Broad thin Band of Adhesions (spider-web) hanging from an Adherent Ovary and Fallopian Tube. 
(Drawn from photograph.) 



which contained a distinctly different variety of pus. As many as 
half a dozen different foci of suppuration have been found in the 
midst of the adhesions, and in a single Fallopian tube, all separate 
and unconnected with one another. 

Should the infection not be virulent enough to cause suppura- 



444 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

tion of the serum and lymph, this latter substance will undergo 
organization to a greater or less extent, with the result of leaving 
the surfaces which have come in contact permanently adherent. 
The adhesions thus found are variable in kind ; clinically at least 
four varieties are recognized. 

The Fallopian tubes, ovaries, and uterus, one or all, may be 
covered with a thin layer of false membrane, well organized and 
not at all unlike a spider-web, when spread out and held up to the 
light. The variety has well been called the " spider-web adhesion." 
The membrane is easily torn to pieces and destroyed if the finger is 
pressed through it while it is on the stretch. If, in attempting to 
break through, it is allowed to gather itself together like a bundle 
of sticks, it forms long shreds of adhesions which are exceedingly 
hard to. tear, and in the tearing of which an intestine or bladder 
may easily be injured badly, its walls giving way at the point of 
the adhesions. They are the more difficult to deal with inasmuch 
as the organs are usually movable under them, and it is hard to get 
any fixed point from which to break through. 

The next variety is that where any or all of the pelvic organs 
become fixed in the lymph in much the same manner as if they 



IV 




Ovary Displaced and bound Down in the OuZ-de-sae by Adhesions— adhesions of the spider-web variety, 
similar to those shown in Fig. 206: ro, right ovary; lo, left ovary. 

were set clown in a bed of plaster of Paris. The lymph organizes 
and from it is formed a new and apparently real peritoneal cover- 
ing. Clinically, to the touch, the organ feels as though it had been 
congenitally developed in its displaced and distorted position. In 



PELVIC INFLAMMATION. 445 

the case of the ovary the ovarian ligament is destroyed ; where the 
Fallopian tube is involved the broad ligament has, to a greater or 
lesser extent, disappeared. The organs are immovably fixed, and 
can only be torn away from their position by an absolute enuclea- 
tion, there being practically no pedicles to deal with : to all intents, 
the mass removed is a sessile growth, and must be dealt with as 
such. The cases in which this condition is found are usually old 
chronic ones. 

The ordinary adhesion met with in the course of operations is 
what one might call the " bread-and-butter" variety. After the ad- 
herent surfaces have been freed from each other the appearance is 
not unlike the surface of two pieces of bread and butter which have 
been placed together as in a sandwich and separated. These adhe- 
sions are more or less firm as the case is an acute or chronic one. 
At times they are so solid that it is necessary to take the handle of 
the scalpel or other instrument in order that they may safely be sep- 
arated ; in other cases the finger will readily destroy them. Should 
the lymph going to form these adhesions become infected, they 
become more or less broken down, and are proportionately easy to 
deal with. This forms the fourth variety as seen clinically. Nat- 
urally, the only pathological difference between at least the last 
three varieties is the difference in the extent of involvement and 
organization. They all begin by the affected organs becoming 
imbedded in a quantity of plastic lymph. This lymph organizes or 
is partially broken down by the infectious poison. If it breaks down 
and fails to organize, the last clinical variety is produced. This 
variety usually accompanies acute pus-tubes. Should it fail to do 
more than make an attempt at organization, the adhesions will go 
to make up that variety which is the most common, the "bread- 
and-butter " variety, which generally accompanies chronic (adhe- 
rent or interstitial) salpingitis. It is almost always possible in enu- 
cleating the organs in such a case to find the broad and ovarian liga- 
ments and use them as a pedicle, although at times they are much 
shortened. If the case runs on into a chronic form, either of the 
last two varieties may develop, by absorption of the degenerative 
elements and by organization and contraction, into those varieties 
which resemble so much congenital conditions. 

Finally, the lymph may break down into suppurating foci at 
one or more points, local abscesses being the result. These abscesses, 
being bounded by adherent lymph, are for all practical purposes 



446 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

extraperitoneal, and yet they are as truly, from an anatomical point 
of view, intraperitoneal as if they were not limited at all. As a 
matter of fact, they exist from cavities as large as a pea to abscesses 
filling the whole of the pelvis, and only being shut out from the 
general abdominal cavity by the intestines and omentum at the pel- 
vic brim, becoming involved in the advancing inflammation, lymph 
being thrown out, and these organs becoming firmly adherent over 
and about the pelvic inlet. 

Unless the attack has been a mild one, the connective tissue 
immediately underlying the peritoneum is apt to become involved 
in the destruction. So intimately connected are the two structures 
that where the one is affected by such a serious process it can readily 
be understood why the other also becomes involved. As soon as 
this loose areolar tissue is invaded, the products of inflammation are 
thrown out into its meshes, and the parts affected become much 
thickened. The connective tissue of the broad ligament and that 
underlying the peritoneum which lines the pelvic floor are most apt 
to be affected. The infiltration, as usual up to a certain point, 
attempts to undergo organization, but mostly fails. It is either 
absorbed or suppurates. 

Should it become absorbed, it would do so in conjunction with 
the absorption of the inflammatory products in the peritoneum and 
in the line of progress toward the cure of the whole pelvic inflam- 
mation. If organization partially occurs, a contraction of all the 
tissues takes place, with the result in some cases of almost total 
obliteration of the ligaments and contained connective tissue. This 
is the condition which has existed in those cases of prolapsed and 
adherent tubes and ovaries, where the ligaments have almost, if not 
entirely, disappeared and the organs remain practically as sessile 
masses. Cellulitis is essentially an acute or subacute as well as a 
secondary disease. It rarely occurs in the pelvis as a primary dis- 
ease, and is just as rarely found as a chronic condition, except 
in the form of an abscess; which is not common. The abscesses 
and masses in the pelvis formerly looked upon as cellulitis are 
almost without exception contained within the peritoneal cavity ; 
where the abscess does exist in the cellular tissue, it is generally an 
extension from a focus of suppuration in the peritoneum. It is 
said that in acute puerperal cases the infection, at times, extends by 
way of the lymphatics directly into the cellular tissue, and results 
in the formation of a true cellulitis and a true primary cellular- 



PELVIC INFLAMMATION. 447 

tissue abscess. Examples of such cases have from time to time 
been placed on record by reliable authorities, but they must be of 
exceedingly rare occurrence, as the writer during the course of 
many hundreds of cceliotomies has failed to find a single exam- 
ple of the condition. In no case, except in suppurating cysts, 
has a pelvic abscess been observed which was not intraperitoneal, 
in the sense that it had originally developed in the peritoneal 
cavity. 

These pelvic abscesses, whether of peritoneal or cellulitic origin, 
are extremely apt to burrow their way to the surface and discharge 
their contents in a more or less irregular manner. They have been 
known to empty themselves into the rectum, vagina, and bladder. 
The umbilicus, the saphenous opening, the pelvic floor, the labia, 
the pelvic foramina, have all served as means of passage for the 
pus. Cases have even been reported where the pus has burrowed 
through the connective tissue to the iliac fossa, and from thence to 
the diaphragm, finally rupturing into the lung. The spontaneous 
evacuation of pus by any of these sources, although a proportion 
of such cases go on to a good recovery, is a disaster, and the danger 
of such a result is one of the clearest of indications for the adoption 
of vigorous measures to ensure its prevention. The usual course 
of a case after such a mishap is a prolonged convalescence — -just as 
commonly a long invalidism, followed by death. The sinus-tracks 
are long and irregular, and the abscess-cavities very incompletely 
drained. In the case of the rectum and the bladder the cavity is 
continually contaminated by the contents of these organs, and an 
already bad condition is rendered worse. 

Symptoms. — These vary in accordance with the anatomical parts 
attacked and the intensity of the inflammation. 

The amount of suffering incurred by the patient will vary from 
a matter of slight discomfort to agony which is quite beyond 
description. There is no death from which a woman may die 
which is, in all its features, more distressing than a death from 
peritonitis, especially an acute septic peritonitis. The symptoms 
of each of the parts attacked are in many respects similar. The 
involvement of almost all the tissues of the pelvis follows as a 
complication wherever the brunt of the attack may fall. In other 
words, one tissue is seldom involved without all being more or less 
included ; consequently the symptoms which would be induced by 
the attack of one tissue are present at the same time with those 



448 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

which would be induced by the involvement of any or all the other 
tissues. 

There are three symptoms which are present in greater or lesser 
degree in almost, if not quite, all cases of pelvic inflammation. 
Pain, hemorrhage, and uterine discharges usually dominate all 
other factors in cases in which suppuration has not supervened. 
Naturally, the temperature and pulse play a conspicuous part. 
When suppuration occurs, all the symptoms of septicemia are 
added to those already existing. In addition, symptoms referable 
to special organs and due most frequently to sympathy and reflex 
influences become at times prominent. 

Salpingitis. — In acute or chronic catarrhal salpingitis the symp- 
toms are seldom sufficiently prominent to give rise to any suspicion 
that there is such a disease present. In the acute form the patient 
will most probably feel a condition of general malaise, have some 
backache, with a possible headache ; there may be a slight increase 
of the discharge coming from the vagina. No noticeable change 
takes place in the menstrual function, for the reason that this is 
already, in all probability, disordered from a pre-existing endo- 
metritis, and the lesion in the tube is too slight to add anything 
perceptible to the result. If at this time the temperature and 
pulse should be taken, the one would be slightly elevated, the 
other accelerated. No doubt in every acute case these symptoms 
are present to a greater or lesser degree, but in almost every instance 
the attack is so slight that it is passed over without notice, and the 
disease has soon settled itself down into a subacute or chronic form : 
in this condition the symptomatology is even slighter than in the 
acute form. The disease is so constantly associated with endo- 
metritis, being, as a matter of fact, almost always an extension of 
the uterine inflammation, that the symptoms of the primary dis- 
ease are a great factor in obscuring those of the salpingitis. The 
fact that the disease has existed at all is usually only discovered 
when its results are made manifest. It is from this form of the 
pelvic inflammation that hydrosalpinx arises. 

Hydrosalpinx. — The distension of the Fallopian tube with serum 
frequently exists without giving rise to any symptoms whatever. 
If the resulting tumor is not very large — and usually it does not 
reach a size greater than that of a Messina orange, although occa- 
sional cases are reported of enormous size — there is no particular 
reason that it should cause any disturbance. When it does so, it 



PELVIC INFLAMMATION. 449 

will most generally be found that an inflammation, slight or other- 
wise, has invaded the peritoneum, and that whatever symptoms are 
present will be due in great part to the local peritonitis. Adhe- 
sions may result or not, this being determined by the character of 
the peritonitis. Should inflammation of the serous membrane 
complicate the case, it will give rise to pain, either slight or 
quite severe according to the grade of inflammation and the extent 
of the adhesions. Leucorrheal discharges are apt to enter as a 
factor into the case : the discharge is of a whitish character, and 
seldom if ever assumes a muco-purulent form. Should the dis- 
charge be muco-purulent, it is evident that it originates from the 
endometrial inflammation, and is not merely clue to the congestion 
caused by slight local peritonitis. Menstrual disturbance is apt to 
be present, as is the case with most examples of pelvic inflamma- 
tion ; the flow is apt to occur too frequently and to be profuse. 

Hematosalpinx — Should the exudate from the mucous membrane 
of the Fallopian tubes take on a bloody character and the openings of 
the tube become occluded, the result is an hematosalpinx. The symp- 
toms of this disease differ in no way from those of the hydrosalpinx, 
or those of the adherent or interstitial salpingitis which will be de- 
scribed later. As in the latter disease, the greatest amount of its 
symptomatology is derived from the peritoneal involvement, and, as 
the extension of the inflammation to the serous membrane is of about 
equal occurrence in both, the symptoms are usually the same. 

Interstitial Salpingitis and Ovaritis. — The name is given this 
form of pelvic inflammation for want of a better one by which to 
designate it. It is meant to include all forms of inflammation of 
the Fallopian tubes and ovaries, excepting those mild ones described 
under the name of catarrhal salpingitis and those described under 
tubercular salpingitis. Leucorrheal discharge will be the first in- 
dication of the trouble, and this will quickly be followed by pain. 
The vaginitis and endometritis which precede the salpingitis will 
have been ushered in with muco-purulent discharges. These dis- 
charges continue when the Fallopian tube becomes involved, and 
the only difference then to be noted is that there is added to them 
the discharges from the tubes. This addition is not sufficient under 
ordinary circumstances to be perceptible. Should the tubal dis- 
charges accumulate and distend the tube, it not infrequently 
occurs that the obstruction at the uterine end finally gives way, 
and there is consequently a gush of muco-purulent matter from 



450 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

the uterus and vagina. One must be on his guard, however, 
against this symptom as indicative of an over-distension of the tube 
and its spontaneous discharge into the uterus. This is presumed to 
be one of the methods Nature has of curing pyosalpinx, and one 
which, if we are to believe all the reports in the literature on this 
subject, is extremely common. There is no doubt but that such a 
happy termination does occur in some few cases, but their frequency 
is questionable. The symptom oftentimes only exists in the mind 
of the attendant and the patient, and is due for the most part to 
faulty observation. Some slight temporary obstruction arises in the 
cervical canal, and the discharges accumulate in the uterus, only to 
be expelled as the patient assumes a favorable position ; or, what is 
more common, there is an accumulation in the posterior cul-de-sac 
of the vagina, with a subsequent discharge on certain movements of 
the woman favorable to their expulsion. The symptom is most apt 
to occur in women who are confined to bed, the recumbent position 
favoring such a condition. Leucorrheal discharges are common to 
all inflammatory or congestive conditions of any or all of the pel- 
vic organs. They are therefore not at all diagnostic, and are only 
of value as corroborative evidence. Their character varies as they 
are mixed or not with infection. The purely congestive discharges 
— such, for example, as precede menstruation and accompany preg- 
nancy — are of a milky-white character; those which accompany 
gonorrheal infection or puerperal septicemia assume a muco-puru- 
lent character. It is this latter kind of discharge which almost 
always accompanies interstitial salpingitis. As a matter of fact, it 
is a combination of the excretions of the tubes, uterus, and vagina, 
and is made up of the suppurating inflammatory effusions, mucous 
and epithelial cells. The discharge is frequently acrid, and causes 
a pruritus of the vulva. Pruritus is not so common a symptom 
in these inflammatory diseases as we would be led to imagine from 
the amount of the discharges, their acridity, and the constancy with 
which they exist. So infrequently does it occur, in fact, that a grave 
doubt arises as to whether the pruritus is ever due to the discharge. 
Leucorrhea is as apt to appear in the same amount where the inflam- 
mation has attacked the tube alone as where the whole pelvic peri- 
toneum is involved. 

Pain is a constant companion of the pelvic inflammatory dis- 
eases. It varies in intensity with the tissues involved and the extent 
of the process. In cases of adherent salpingitis and ovaritis it is 



PELVIC INFLAMMATION. 451 

usually located in one or both iliac regions, at times extending 
down the thighs, and is frequently accompanied by backache. It 
is severe or not as the attack is an acute or chronic one. Its cha- 
racter is variable, from a dull, heavy backache to a sharp, lancinat- 
ing iliac pain, which does not come and go, but remains, for the 
most part, constant. Often it is due more to the irritation of the 
advancing inflammation than to any real involvement of the tubal 
or ovarian tissues. It is no infrequent thing in gonorrheal or puer- 
peral endometritis to find that the iliac pain disappears after a 
thorough curettement of the uterus, proving that the inflammation 
has not yet passed beyond the uterine cavity. The sharp pains are 
mostly due to peritoneal involvement, and are a fairly sure indica- 
tion that this membrane has been invaded by the actual inflamma- 
tion, or at least is irritated by its near approach. The ovarian 
involvement is, however, responsible for a fair share of the condi- 
tion. The dull, heavy pains, as the backache, are most probably 
produced by the infiltration of all the tissues with inflammatory 
products ; possibly some of the elements of the peritoneal pain are 
added as a factor. Motion or pressure of any kind will aggravate 
this symptom. An over-distended bowel or bladder gives more or 
less distress, and the contraction incident to the emptying of either 
of them causes considerable suffering. Walking, riding, or jarring 
from any cause calls forth this complaint : even the erect position 
may be uncomfortable or unbearable. 

Menstrual disturbances are universal. As a rule, menstruation 
appears too frequently, every two or every three weeks, and lasts 
from the usual time to eight or ten days : occasional cases last for 
so long as two weeks. It is important in weighing this symptom 
to inquire carefully into the past menstrual history. Not uncom- 
monly, women present themselves for treatment in whom a frequent 
and prolonged menstruation is natural, and this condition must not 
be confounded with a pathological one. Where the flow has form- 
erly been fluid, under the altered condition it is apt to become 
clotted and dark. The function is accompanied by pain, which 
may appear some days before the flow and last several days after 
it has ceased. Like all the other symptoms, this one is variable, 
and in not a few cases the flow is scant rather than profuse. Scanty 
menstruation is the exception in inflammatory diseases of the Fal- 
lopian tubes, but that it does exist is undoubted. Suppuration of 
the exudates and an accumulation of pus in the tubes have no very 



452 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

perceptible influence upon these symptoms. Pain, hemorrhage, and 
leucorrheal discharges seem to depend largely upon the amount 
and character of the involvement of the serous membrane; cer- 
tainly pain is almost absolutely dominated by this factor ; possibly 
the altered mucous membranes have the most influence upon the 
other two symptoms. The three symptoms grouped together in 
conjunction, with a history of gonorrheal infection or of post- puer- 
peral septicemia, are highly suggestive, and yet not much reliance 
can be placed on a diagnosis based upon this data. The three 
symptoms, alone or grouped together, accompany almost every 
disease to which the pelvic organs of the female are heir. These 
symptoms, however, taken in conjunction with certain local condi- 
tions, establish the diagnosis almost certainly. 

As in all inflammations, the temperature and pulse are affected. 
Usually neither of them rises to any very great extent. During the 
first few days of the acute attack they may both be elevated consid- 
erably above 100°. As seen in the subacute or chronic condition, 
it is rather uncommon to note any great deviation from the normal 
where suppuration has not occurred or where the peritoneum is 
only slightly or not at all involved. If the attack has been ushered 
in with a chill or rigor, it is almost certain that either one of these 
two conditions exists. As a matter of fact, peritonitis and cellulitis 
almost always accompany and complicate the salpingitis, and conse- 
quently the symptoms of the two conditions always commingle. 

The tendency of inflammation near or about the bowel is to in- 
hibit peristaltic action, and constipation is the rule. As constipation is 
almost the natural condition of women, however, it adds little to our 
diagnostic resources. On the other hand, the bladder becomes irri- 
table under the same condition, and the presence of the urine causes 
a frequent desire of the bladder to empty itself. Frequent mictu- 
rition and constipation are common symptoms. Any irritation in 
the pelvis seems to give rise to gastric disturbances, and the inflam- 
matory diseases are no exception. Symptoms of dyspepsia, espe- 
pecially flatulence, are very common, and, in fact, at times give rise 
to more distress than the symptoms referable more directly to the 
pelvic lesions. Distension of the intestines with gas occasions con- 
siderable pain at times — a pain which comes and goes, and which is 
distinctly different from the inflammatory pains. 

Pyosalpinx and Ovarian Abscess. — Should the inflammation prog- 
ress to suppuration, many of the symptoms are apt to become exag- 



PELVIC INFLAMMATION. 453 

gerated, and in addition there is added the condition of sepsis. 
The woman begins to suffer from cold creeps, chills, or even a rigor ; 
the temperature becomes elevated, ranging from 100° to 104°, or 
even higher ; the pulse rises rapidly, and varies from 100 to 140 or 
more beats to the minute. The abdomen becomes swollen, due to 
distension by gas, the walls hard, unyielding, and exceedingly ten- 
der to the touch. The skin surface may become cold and clammy, 
the appetite destroyed, the sleep restless and unrefreshing. A gene- 
ral feeling and appearance of dulness, or even stupor, may super- 
vene. The pain is more persistent and intensified, and is apt to 
assume a more or less deep, throbbing character. As time passes the 
woman's general condition gradually grows more and more serious. 
She loses many pounds of flesh and becomes greatly emaciated ; her 
face has a distressed and shrunken appearance ; her nervous sys- 
tem becomes shattered ; she may or may not be confined to her bed. 
It might easily be concluded from these remarks that no great reli- 
ance could be placed upon symptomatology in the diagnosis of 
inflammatory tubal disease. Such is, in truth, the fact. It is abso- 
lutely necessary that the physical signs be determined by vaginal 
examination before the truth can be ascertained. 

Peritonitis. — The symptoms attributable to this disease are a 
combination of those produced by the inflammation of all the other 
parts of the pelvis. As a matter of fact, the main symptoms attrib- 
utable to pelvic inflammatory cases are produced by the inflamma- 
tion of the serous membrane. Many of the symptoms described 
under different forms of salpingitis originate in or are increased by 
the peritonitis. Inasmuch as peritonitis to a greater or lesser extent 
complicates the inflammations of the Fallopian tube, the symptoms 
are practically the same, their severity depending much upon the 
extent of the lesion. If only the peritoneum covering the Fallo- 
pian tube be involved, then the symptoms will be similar to 
those already described. When the whole pelvic peritoneum is 
invaded, the pain is more acute; the temperature and pulse are 
more markedly elevated; the patient lies more comfortably with 
the knees drawn up, for the reason that it relaxes the abdominal 
muscle and takes away a considerable amount of the intra-abdomi- 
nal pressure ; the expression of the face is apt to be distressed ; the 
abdominal muscles rigid and fixed ; the whole abdomen tender to 
the touch ; the intestines distended with gases, rendering the belly 
tympanitic; the appetite abolished and sleep impossible. Consti- 



454 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

pation is absolute and there are eructations from the stomach. Such 
is a fairly typical description of a severe attack of pelvic peritonitis. 
There are, in addition, all the symptoms present which have been 
enumerated as accompanying inflammation of the Fallopian tube, 
together with those present when the cellular tissue is involved ; 
which is generally the case. Should suppuration of the exudates 
occur, there will be added the symptoms of septicemia. The differ- 
ence of these symptoms from those arising in a suppurating salpin- 
gitis will be more of degree than of kind. In the abscess forming 
in the abdominal cavity, either as a small pocket in the midst of 
the lymph or as a general abscess of the whole pelvic cavity, the 
absorption is apt to be more rapid than if confined to the Fallo- 
pian tube. 

Cellulitis. — The symptoms attributable to this disease are indis- 
tinguishable from those of peritonitis. The two affections go hand 
in hand, and any attempt to classify their symptoms would only be 
theoretical. As a matter of fact, they cannot be distinguished 
clinically. A simple infiltration of the cellular tissue with inflam- 
matory products would produce no other symptom than possibly 
a feeling of weight and fulness, but this discomfort would be so 
overshadowed by the severe suffering from the peritonitis as hardly 
to be noticed. In those rare cases in which primary abscesses 
occur in the cellular tissue, following or accompanying the puer- 
perium, nothing distinctive is noticed until suppuration occurs, 
and then the symptoms are simply those of septicemia. An attempt 
to classify and compare, for differential purposes, the symptoms 
of cellulitis and peritonitis is of no more than problematic value ; 
it is of no practical benefit. Clinically, the two affections are 
indistinguishable, for the reason that they always complicate each 
other, and their symptoms are so closely interwoven. The symp- 
toms of cellulitis, which is mostly secondary, are few and un- 
important and are completely overshadowed by the far more 
important and severe symptoms of the peritonitis, the primary 
disease. 

Physical Signs. — In an attack of pelvic inflammation there 
is always a fairly regular routine followed, and the results are 
essentially the same, differing only in degree. Every case is in 
this respect a law unto itself, and in no two of them are the Fallo- 
pian tubes and ovaries equally degenerated and distended, nor are 
they always found in the same position. The physical signs are so 



PELVIC INFLAMMATION. 455 

closely interwoven that all the elements must be considered together 
if they are to be viewed to the best advantage. 

Catarrhal Salpingitis. — Physical signs are entirely absent. There 
is no infiltration of the tube-walls, and no peritonitis or cellulitis, with 
attendant exudate of lymph and infiltration of inflammatory prod- 
ucts. The Fallopian tube is almost, if not entirely, as soft as in 
its normal condition, and if there is any enlargement it is simply 
due to a mild congestion. For practical purposes it may be con- 
sidered that in the average woman of ordinary size the Fallopian 
tube cannot be palpated. Such may be said to be the case also in 
catarrhal salpingitis. 

Hydrosalpinx. — In this form of the disease the uterus may or 
may not be freely movable. Most frequently it is movable, as the 
Fallopian tube is either not adherent or so lightly so as not to 
affect the womb. The mobility of the uterus in health varies so 
much that it is often difficult to decide whether or not it is 
impaired. More frequently, both Fallopian tubes are involved, 
although it is no unusual thing to find only one side affected. By 
deep palpation to the sides of the womb a cystic tumor, varying 
in size and shape, will be felt. The tumor is elongated, and can 
be traced with the finger from the side of the pelvis to the uterine 
cornua. It is distinctly felt to be free from the uterus and inde- 
pendent of that organ. Usually, a sulcus can be recognized between 
the two. The examination may simply disclose a large cystic tumor 
with nothing characteristic about it ; in either case the growth may 
be fixed by adhesions and rendered immovable, or it may readily 
be displaced in any direction. The opposite side may be found in 
the same condition, or the examination may disclose nothing as 
regards its involvement. It is often found in a state of simple 
catarrhal salpingitis. 

Very much the same can be said in regard to that phase of the 
disease in which the tube is distended with blood, as has been said 
of hydrosalpinx. Hematosalpinx has no distinguishing features. 
It differs from hydrosalpinx only in that it is apt to be smaller, 
with thicker walls, and more likely to be adherent, and conse- 
quently immovable. The affection is most usually unilateral, 
and is often complicated on the opposite side by an interstitial 
salpingitis. 

When the walls of the Fallopian tube are infiltrated with 
inflammatory products and its peritoneal covering involved, an 



456 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

examination of the pelvis will reveal a condition depending upon 
the severity of the attack and the extent of its advance. The uterus 
will be found to a greater or lesser extent immovable, as well as en- 
larged. It will be adherent in a displaced position or not, depending 
upon its location in the pelvis at the time of the attack of inflam- 
mation. In the milder attacks the Fallopian tubes will be easily 
felt to the sides of the womb as hard, elongated cords, adherent, 
immovable, and extremely painful to the touch. The organ can 
readily be traced to the uterine cornua, and a sulcus may be felt be- 
tween the two. The ovaries will be found about halfway between 
the pelvic wall and the uterus on either side, enlarged, hard, and 
adherent. The size of the tube and ovary, as well as that of the 
uterus, will depend upon the amount of involvement of the cellular 
tissue, but more particularly upon the extent of involvement of the 
peritoneum and the amount of lymph thrown out. A Fallopian 
tube and ovary which together appear in situ to be as large as a 
four-ounce bottle will not infrequently be found, on removal, not 
more than two or three times the natural size : the remainder of the 
bulk is found to have been made up of plastic lymph, which is to 
a great extent destroyed as the adhesions are broken up. The size 
of the womb is at times also more apparent than real, the enlarge- 
ment being due also to the surrounding lymph. For the most part, 
however, the womb is actually enlarged by the inflammatory infil- 
trate into its walls, brought about by the primary endometritis. As 
often as not the uterine appendages are displaced, and may be found 
in any part of the pelvis. Both tubes and both ovaries have been 
observed on the same side, the one ovary being displaced in some 
manner, and found directly adherent on top of the opposite one. Not 
infrequently, when the uterus is retrodisplaced, either one or both 
appendages will be found posterior to this organ, and so high up 
as to be out of reach ; they are consequently often overlooked. 
The disease is generally bilateral, and the same condition can be 
felt on both sides ; at times, however, it is only unilateral. When 
there is acute involvement of the whole of the peritoneum on the 
floor of the pelvis, as well as of the connective tissue underlying 
it, a sensation of fulness in all directions will be felt, its hardness 
depending upon the amount of infiltration and the chronicity of 
the case. 

Should the tubes and ovaries be distended with pus, they will 
be found on palpation in much the same condition as that just 



PELVIC INFLAMMATION. 457 

described. If the pus be present in considerable quantities, the 
masses may fluctuate or give to the touch a sensation of softness, 
and in very exceptional cases may feel not unlike ordinary cysts. 
Should small abscesses exist in the lymph or connective tissue 
surrounding the uterine appendages, they cannot be detected. 
When these intraperitoneal abscesses extend and involve a con- 
siderable part of the pelvis, advancing even into the connective 
tissue, the whole pelvic vault conveys a hard, board-like feeling to 
the examining finger — a condition which extends as far as the finger 
in the vagina can explore. It is not uncommon to find an infiltrat- 
ing ring higher up about the rectum. This ring is due to connec- 
tive-tissue infiltration, and does not usually break down into sup- 
puration. Through the abdominal walls a hard mass of no definite 
shape or consistency can at times be felt, which is made up for the 
most part by adherent intestines and omentum. Ordinarily, the 
infiltrating masses cannot be felt through the abdominal walls 
except with the patient under the influence of ether : only in cases 
of pelvic abscess do these large irregular masses rise into the 
abdominal cavity high enough to be felt readily by abdominal 
palpation. 

Diagnosis. — The establishment of the diagnosis of pelvic 
inflammation is difficult or not according to the stage at which 
the disease has advanced and according to the virulence of the 
infection. 

Catarrhal Salpingitis. — It is not possible to diagnose this form 
of disease except by inference. Symptoms are so slight as not 
particularly to call the patient's attention to her pelvic organs 
unless she is already suffering from endometrial disease ; in this 
case the symptoms caused by the infection of the uterine cavity will 
so greatly overshadow all those of the salpingitis that she will have 
no cause even to suspect that her Fallopian tubes are becoming 
involved. Even should the disease be suspected, there is no way in 
which the suspicion can be verified, for the reason that the Fallo- 
pian tube can only be palpated in exceptional cases, and even 
should it be felt, the changes in its tissue are so slight that they 
could not be distinguished by the touch. Later on, when sterility 
is demonstrated or a hydrosalpinx is discovered, the relation of 
cause and effect may be seen. The sterility may, however, be caused 
by intra-uterine disease, in which case, until the specimen is 
actually under the microscope, it is not always possible to make the 



458 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

diagnosis, even by inference. An element of doubt would exist 
under the most favorable circumstances, rendering speculation or 
theory absolutely useless for practical purposes. 

Hydrosalpinx. — It is always possible to come to the conclusion 
in this phase of the disease that there is present in the pelvis a 
tumor which does not belong there. It may even be possible in 
some cases to say positively that this form of the disease exists. 
Theoretically nothing should be easier, but practically many ele- 
ments combine to defeat the desired result. The tumor caused by 
a hydrosalpinx is mostly unilateral, and will be found in the posi- 
tion which should be occupied by the Fallopian tube and ovary. 
If a tumor be found in this position and its character be doubtful, 
an examination with the patient under ether will often clear up the 
doubtful points. The walls of this neoplasm are thin and the tumor 
fluctuates. The amount of fluctuation will depend largely upon the 
size of the growth, the consequent thinness of its walls, and upon 
the number and density of its adhesions. At times it is entirely 
free from adhesions, and is as freely movable, within the limits of 
the mobility of the Fallopian tube, as would be an ovarian cyst. 
Should the tumor be a large one, it will assume a rounded shape 
not unlike a cystic ovary. On the other hand, when the tubal dis- 
tension is limited, the resulting tumor will retain the elongated, 
tortuous shape of the Fallopian tube. The principal diseases that 
may be mistaken for this condition are small ovarian cysts, small 
parovarian cysts, hematosalpinx, and extra-uterine pregnancy. In 
hydrosalpinx the main features in the diagnosis are the elongated, 
sausage-like shape of the tumor ; the fact that it can be traced to 
the uterine cornua at the position where the tube would naturally 
be found; the presence of the ovary independent of the tumor; 
and the fact that it is a cystic growth. The ovarian cyst is always 
rounded in shape, and there is no connection whatever between it 
and the uterus. The parovarian cyst is apt to be much less movable, 
and never has the elongated shape of the hydrosalpinx ; neither has 
it any connection with the uterus such as described. 

It is not possible to distinguish hematosalpinx by the physical 
signs, and the symptomatology is too unreliable to be trusted. The 
fact that the blood-tumor is more liable to be adherent is not suf- 
ficiently practical to be of much benefit. Extra-uterine pregnancy 
can generally be distinguished by its symptomatology and by watch- 
ing its behavior as it grows. It is probable that more frequent mis- 



PELVIC INFLAMMATION. 459 

takes will be made in the case of small parovarian cysts than any- 
thing else. After all has been said, failure oftener than success 
results in an attempt to diagnose hydrosalpinx. 

Hematosalpinx. — What has been said in the case of hydrosalpinx 
is equally true of this disease. The same characteristics of the 
tumor exist, excepting that the hematosalpinx is not apt to become 
so large. However, as there are many cases of small hydrosalpinx, 
this point has no particular value. The tumor is elongated ; it is 
connected at the uterine cornua, as is the case with the normal 
Fallopian tube ; it fluctuates more or less satisfactorily ; if the dis- 
tension be only slight, this sign is worthless. The question of . 
adhesions is also of dubious advantage, as any of the products of 
pelvic inflammation are almost certain to be adherent. The one 
sign which may be of advantage in the diagnosis of either hemato- 
salpinx or hydrosalpinx is the division of the elongated tumor into 
compartments, or an apparent attempt in this direction. The 
healthy Fallopian tube is so divided, and it is frequently the case 
that a tube distended by fluid contents has two or more compart- 
ments. These can at times be appreciated by the touch, and in case 
they are a diagnosis can probably be arrived at. 

Interstitial Salpingitis and Ovaritis. — Nothing is more deceptive 
than the symptomatology in pelvic inflammations. A woman may 
present herself complaining of all the symptoms of diseased, dis- 
organized appendages, and yet an examination fail to establish such 
a diagnosis. A patient may give a history of having been married 
for some years and of having had one or more children. She has 
remained in good health until in her last confinement or miscarriage, 
when she has had septic trouble, indicated by a swollen and painful 
abdomen, together with fever; or her trouble may have begun 
with a well-marked attack of gonorrhea. From this time until she 
consults her physician she is not in good health. Pain is a con- 
stant companion, being referred to the iliac regions or the back. 
There is pain on coitus, defecation, riding in the cars, walking, or 
sitting down, and under any circumstances which will cause a dis- 
placement of the pelvic organs. The menstrual function, which was 
originally normal, is now profuse and irregular. Muco-purulent 
discharges exist ; the patient suffers from chilly feelings at times, 
and loses flesh. The history in such a case is complete, and if the 
symptoms alone are depended upon to make the diagnosis, the most 
skilled physician will probably be often led astray. Such patients 



460 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

continually report themselves, and a bimanual examination even 
under ether fails to confirm a diagnosis of pyosalpinx or of chronic 
interstitial salpingitis, although the entire pelvis may be exquisitely 
tender to the touch. In such cases, where the abdomen has been 
opened for exploration, the peritoneum and cellular tissues have 
frequently been found to be healthy, as far so a macroscopical exam- 
ination could determine. It is altogether unjustifiable to send a 
patient to the operating-room, presumably suffering from the results 
of pelvic inflammation, without first having made a thorough and 
searching examination of the pelvic organs by bimanual palpation ; 
and if there is any doubt as to the existence of any lesion, the 
examination should be made with the patient under ether. The 
combination of the symptomatology and physical signs will gene- 
rally succeed in establishing a correct diagnosis in these diseases. 
However, unless one of the Fallopian tubes or ovaries can be pal- 
pated, and plainly demonstrated as being enlarged and diseased, the 
diagnosis cannot be said to have been established. The symptoms 
can generally be traced to a labor, a miscarriage, or an attack of 
gonorrhea. A very large number of the patients have had an 
" inflammation in the stomach," or give a history of having had 
typhoid or malarial fever in or following the puerperium ; their 
symptoms have dated from or about this time ; sterility is a prom- 
inent and constant feature. The principal indications of the under- 
lying trouble are the pain and the disordered menstrual function, and 
not infrequently there is a history of one or more attacks of peri- 
tonitis. A vaginal examination usually discloses an adherent and 
more or less immovable uterus. In a goodly number of cases, how- 
ever, the uterus will not be found fixed, but movable within certain 
limits. An attempt to displace the womb will elicit pain, whether 
it be adherent or not, the pain being caused for the most part by the 
dragging upon adhesions, either those involving the uterus or those 
encircling the Fallopian tube and ovaries. The pain will be greater 
or lesser in proportion as the inflammation about the parts has 
subsided. 

To the right or left on both sides of the womb the Fallopian 
tubes and ovaries may be felt. The tubes are enlarged, thickened, 
and adherent. Attempts at displacing them result simply in causing 
pain ; the whole pelvic vault is tender when the inflammation has not 
subsided. The Fallopian tubes will be felt as elongated, tortuous 
bodies in the position of the normal organs, extending from the 



PELVIC INFLAMMATION. 461 

side of the pelvis to the uterine cornua. In some cases the ovary, 
from the fact that it is prolapsed to a lower level than that of the 
tube, forms the greater bulk of the mass presented to the examin- 
ing finger ; slightly deeper palpation will, however, usually disclose 
the elongated tube. Occasionally it happens that the uterus is retro- 
displaced, and the appendages are one or both of them twisted pos- 
terior to the fundus, and, unless the patient is under the influence 
of ether, cannot be distinguished. So closely attached are the 
appendages at times to the womb that the whole mass appears as 
one body, and it is only by the irregularity of the mass and the 
existence of a sulcus between the diseased appendage and the womb 
that the true condition can be distinguished. An examination by 
the rectum which permits of the examining finger being passed pos- 
terior to and above the uterus and broad ligaments will often decide 
these points, where no definite conclusion could be arrived at by the 
combined vaginal and abdominal touch. In the acute condition, 
where the aj>pendages are surrounded by and buried in masses of 
peritoneal lymph and the cellular tissue is involved, they will appear 
to be of great or indefinite size. The whole vaginal vault may be 
so hard and board-like that it will be impossible to distinguish the 
appendages through the general mass of lymph. In the more 
chronic form, when the lymph and cellular exudate have in great 
part been absorbed, the tube may present itself only as large in 
diameter as an ordinary lead pencil. It is not very probable that 
there will be a failure to diagnose the disease, excepting where it 
has undergone suppuration and assumes more or less the character 
of a cyst. These enlarged and thickened tubes and ovaries, densely 
adherent and often surrounded by masses of peritoneal lymph and 
cellular exudates, taken together with the history and symptoms, 
can hardly be misunderstood. There are few conditions for which 
this disease is likely to be mistaken. 

Every woman suffering with the lesions of a pelvic inflamma- 
tion is liable from time to time to have the inflammation recur. 
Frequently the inflammation never leaves the parts, but remains 
as a low-grade chronic disease, ready to relight into an acute 
exacerbation on the slightest pretext. In other women it sub- 
sides entirely and the parts become quite free from pain. In 
such a case there is less likelihood of recurring acute attacks, but 
yet they do occur. A woman carrying diseased tubes and ovaries 
due to pelvic inflammation may be confined to her bed as often 



462 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

as three or four times a year, for from two to eight weeks at each 
attack. Usually the recurrence is not so severe, and may not hap- 
pen oftener than once every year or two ; others only last a few 
weeks, frequently not even confining the woman to bed. Exposure 
to cold, excessive indulgence in coition, violence on the part of the 
husband, working tread-machines, hard work of a hundred and one 
different kinds, generally determines the exacerbation. During the 
menstrual period the women are peculiarly liable to these attacks. 
The physiological congestion of menstruation may very readily be 
turned into a pathological condition, and an inflammation result. 
Women afflicted with pelvic inflammations frequently suffer from 
attacks of apparent peritonitis which simulate to a great degree the 
true inflammation. The abdomen and pelvis at the time of the 
examination are found to be exquisitely tender, and not infre- 
quently an investigation is rendered impossible. By persisting 
firmly but gently, at the same time calling the patient's attention 
to some other object, a pelvis and abdomen which would barely 
tolerate the approach of the hand may be brought to bear, with- 
out any complaint from the patient, a very free amount of manip- 
ulation. The hysterical element in these cases of long suffering is 
oftentimes great, and it must always be taken into consideration in 
estimating the amount of pain. 

Pyosalpinx and Ovarian Abscess. — Should suppuration intervene, 
there is at once added the element of septicemia. The tube may 
contain but a few drops of pus, in which case the only additional 
aid to the diagnosis would be in the special symptoms produced by 
the absorption of the pus. Following confinement or miscarriage, 
a woman may have a slow and unsatisfactory " get up," or she may 
not get up at all. Her temperature remains in the neighborhood 
of 100° F., while her pulse-beats continue at about 100 or more. 
She has no appetite, suffers with pain in the lower part of the 
abdomen, sleeps restlessly, and has occasional creepy feelings. This 
condition keeps up for months, with a progressive loss of flesh — 
slight, it is true, but steady. An examination reveals a mild form 
of pelvic inflammation, with the usual lesion of the appendages. 
This condition, taken in connection with the history, fairly estab- 
lishes the presumption that pus is present if all other possible 
sources of suppuration are excluded, although it is impossible to 
detect any signs of it by the vaginal examination. Should pus 
accumulate in any great quantity, the Fallopian tubes soon distend, 



PELVIC INFLAMMATION. 463 

and may at times reach the size of large sausages. Should the 
suppuration occur in the tube, in the lymph around the tube, or in 
the ovary, there would be little if any difference in the result. 
Wherever it is located, if the quantity be sufficiently large, the pel- 
vic tumor fluctuates or the whole mass presents a semi-soft or boggy 
feeling. Not infrequently the fluid portion of the suppurating con- 
tents is absorbed altogether, leaving the tube filled with a cheesy 
material which may remain indefinitely and without causing any 
particular disturbance, other than by the mere presence of a foreign 
body in the pelvis. When such a case has been complicated by an 
inflammation of the peritoneum, the same condition may remain, 
and the patient suffer just as much as though the fluid had not 
been absorbed. Fallopian tubes of this character become at 
times the size of large sweet potatoes. It is exceedingly difficult 
frequently to distinguish pyosalpinx and ovarian abscess from 
some other pelvic diseases, notably extra-uterine pregnancy or 
abscess located in other parts of the pelvis. No two pelvic dis- 
eases are so frequently mistaken for one another as pyosalpinx 
and ectopic gestation. A careful study of the history of the patient 
is at times essential to a determination of the difference, and is of 
more value than the physical signs. Extra-uterine pregnancy pro- 
duces symptoms which, if they can be elicited, are characteristic, 
but they are so frequently modified that it is difficult to distinguish 
them. The pain in the two diseases may essentially be alike, at 
least so far as a description of it can be elicited from the patient : 
the physical characteristics of the cysts are not dissimilar, both being 
semifluctuant, located in the same position, of the same shape, and 
of about the same size in the early stages of the pregnancy. The 
uterus is enlarged in both, the menstrual function is disordered, and 
the breast and stomach symptoms are not infrequently similar in 
either case. The casting off of the decidual membrane is by no 
means a constantly demonstrable feature of the extra-uterine preg- 
nancy. The progressive growth of the tumor, if the patient be 
kept under observation sufficiently long, is very suggestive, if not 
positive evidence, of ectopic gestation. 

Suppuration confined to the Fallopian tubes or ovaries is more apt 
to give a circumscribed tumor than suppuration in the plastic lymph 
or connective tissue. In the case of a pyosalpinx or ovarian tumor 
the tube-sac can be felt as a distinct body, adherent and immovable, 
it is true, but still a circumscribed tumor, with a distinct sulcus 



464 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

between it and the uterus. The true pelvic abscess is quite the 
reverse, and oftentimes nothing definite can be made out, only a 
general fulness occupying the pelvis more or less, without any 
definite limitations, and so involving all the pelvic organs that 
none of them can be distinguished. In either case there may or 
may not be fluctuation. 

Cystic tumors are distinguished from a pyosalpinx or ovarian 
abscess by the thickness of the walls of the latter, the more boggy 
feel, the septic symptoms, and the history. A tubal and ovarian 
mass confined to the pelvis, fluctuating, with thick walls, densely 
adherent, painful on examination, with a history of sepsis, can 
hardly be mistaken for anything but a tubal or ovarian abscess 
unless it be an extra-uterine pregnancy. 

Peritonitis. — Pelvic peritonitis in women rarely if ever exists 
without a pre-existing endometritis and salpingitis ; among the 
exceptions it has been noted that an appendicitis has occasionally 
been the source of the disease. These cases are rare, and although 
the vermiform appendix has not infrequently been found in the pel- 
vis perforated and adherent to the Fallopian tube and ovary, with 
abscesses in the surrounding lymph, yet it is always a question as to 
whether the inflammation started in the Fallopian tube or in the 
vermiform appendix. The diagnosis would rest in such a case 
almost entirely upon the history. Wherever the disease originates, 
the result has been observed to be the same — a salpingitis and a 
peritonitis. When the symptoms and diagnosis of salpingitis have 
been considered, about all that can be said about peritonitis has been 
told, for the reason that inflammation of the Fallopian tube and the 
symptoms arising from the combined disease originate mostly in the 
peritonitis. A salpingitis uncomplicated by an inflammation of the 
peritoneum would give rise to but few symptoms. Such is the case 
with catarrhal salpingitis, and even with its resultant lesion, hydro- 
salpinx. It is the peritonitis accompanying the salpingitis that 
causes the formation of the large masses of lymph, the subsequent 
adhesions and immobility of the organs, the pain, the leucorrheal 
discharges (in part), the disordered menstrual function, and, in fact, 
all the prominent symptoms of the disorder. The extent to which 
peritonitis exists in any given case is oftentimes problematic and 
can only be guessed at. The whole pelvis may be involved or the 
lesion may be limited to a fractional part of it. The less of the 
serous membrane involved, the less will be the pain and the. fewer 






PELVIC INFLAMMATION. 465 

the adhesions. In the acute stage of the inflammation lymph is 
thrown out about the parts affected, and the contiguous serous sur- 
faces become attached to one another. These points can be palpated 
and a fairly clear idea of their extent obtained. The exudated 
lymph may be confined about the Fallopian tubes or ovaries, one or 
both, or it may be found that the loops of intestine and omentum 
overlying the pelvic inlet have become involved, and are adherent 
to each other and to the pelvic organs. This lymph exudation and 
adhesion is Nature's method of heading off an inflammation of the 
serous membrane, and it is interesting to note the repeated and con- 
tinued exudation, as the inflammatory process overcomes the areas 
it has first attempted to protect, knuckle after knuckle of the intes- 
tine becoming glued together in front of the advancing infection, 
until the lymph has finally effectually stayed its progress. The 
result in bad cases is an indurated mass in the lower portion of the 
abdomen, overlying and dipping down into the pelvic inlet. With 
the patient's history and the presence of such a tumor it is not hard 
to realize the relation of cause and effect. Such a mass is usually 
more or less tympanitic and immovable. Under treatment, unless 
suppuration has occurred, these masses disappear to a great extent, 
leaving the intestine and omentum adherent, it is true, but as the 
lymph has been absorbed the mass has lost its hard, indurated cha- 
racter, and has assumed more nearly the usual characteristics of the 
soft intestine. In fact, as a distinct tumor the whole mass generally 
disappears ; in some cases, on the other hand, it remains to the end. 
Should suppuration occur, this is the usual course. Suppuration of 
the tubal contents is very common, and is not infrequently associated 
with a breaking down of the peritoneal lymph surrounding the 
appendages at several points, resulting in the formation of one or 
more small abscesses about the appendages. These surrounding 
abscesses are commonly spoken of as occurring in the connective 
tissue, but they arise distinctly from and in the plastic lymph. It 
is not possible to diagnose their existence prior to an operation unless 
they spread and become large enough to overshadow the tubal or 
ovarian abscess. Even then it is more than probable that they 
would be mistaken for an abscess located in the Fallopian tube or 
ovary. As a matter of fact, they do not often become so very large, 
unless the infection has travelled fast and overcome the resistance 
of the obstructing lymph, forming a large pelvic abscess — intra- 
peritoneal as a matter of fact, as are almost all the pelvic abscesses. 



466 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

It is possible at times to say that the pelvic abscess exists, but 
usually the distinction can only be made between a true pelvic 
abscess and a bad case of pyosalpinx by an experienced diagnostician, 
the points of difference being determined by the physician's per- 
sonal experience and delicacy of tactile sense. As a rule, where 
there is a large indurated mass rising into the abdominal cavity free 
pus will be found in the pelvis ; but this is by no means a sure 
sign. When the pelvis is full of free pus, the vaginal vault is apt 
to give a sense of fulness and induration in all directions, as if the 
whole pelvis were filled with a solid mass. This feeling extending 
more or less over the whole of the pelvic floor, none of the pelvic 
organs can be outlined ; the uterus is fixed in its position, whatever 
that may be. Fluctuation may or may not be detected ; frequently 
the pelvic floor is so hard and indurated that this sign is very uncer- 
tain. That a bad pelvic inflammation has existed, and that sup- 
puration has occurred, are usually unmistakable. Anything fur- 
ther in the line of an exact diagnosis must rest on the particular 
features of the special case and the physician's dexterity and 
experience. 

Cellulitis. — What has been said about peritonitis is also true of 
cellulitis. A few cases of this disease may arise in puerperal 
patients by transmission of the inflammation along the walls of 
the lymphatics and suppuration of the cellular tissue. Such cases 
are rare, and if they do exist cannot be diagnosed from the intra- 
peritoneal pelvic abscesses, those which arise within the peritoneal 
sac from breaking down and suppuration of the peritoneal lymph 
and exudates. Inflammation of the cellular tissue always accom- 
panies a severe peritonitis, and the two are indistinguishable from a 
diagnostic point of view. The cellular tissue in the broad ligaments 
becomes involved in the course of a pelvic inflammation, the result 
being a distension of the ligament by exudates and a destruction of 
the cellular elements by the inflammatory process. As the inflam- 
mation subsides, the ligament is contracted or destroyed, which re- 
sult may be recognized at a subsequent investigation after the case 
becomes a chronic one. 

The usual points of distinction between a pelvic cellulitis and a 
pelvic peritonitis, as formulated and compared in all works on gyn- 
ecology, are misleading and worthless. It is utterly impossible for 
any one to make a practical distinction between these two phases of 
a common disease, and the formulae as given only tend to complicate 



PELVIC INFLAMMATION. 



467 



the understanding of what is possible and what is clinically true. 
The difference is purely theoretical ; practically and clinically they 
are part and parcel of the same disease — viz. pelvic inflammation. 
The cellular tissue rarely suppurates except in conjunction with the 
suppuration of the peritoneal exudates. When it does break down, 
it cannot be distinguished, short of operation, from other forms of 
pelvic abscess. The disease, except in the form of an abscess, never 
exists as a chronic condition ; its resultant contraction of the broad 
ligament may exist and be recognized, but the cellular inflammation 
has ended in the acute attack by a destruction of the connective 
tissue. 

After all methods have been exhausted there remain a certain 
small class of cases of pelvic disease in which a positive differentia- 




The fold behind the cervix which lies over the cervieo-vaginal junction is well shown. The vagina is to 
be incised here. (From life.) 

tion of the lesions cannot be made. The conditions are such that it 
becomes necessary to clear up the diagnosis and determine the 
pathological lesions. There are two ways of doing this : either by 



468 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



laparotomy or by posterior vaginal section, as suggested by Pry or. 
Exploratory laparotomy is merely the usual first step as practised 
in every abdominal section and is described under that heading. 



Fig. 269. 




The vagina is incised, and the point at which the peritoneum is reflected from the uterus is shown as the 
deepest part of the cut. The peritoneum is to be torn through at this point. (From life). 

Posterior Vaginal Section. — The patient is placed in the lithotomy 
posture. 

The uterus is curetted and irrigated. All instruments employed 
in this procedure are then cast aside and the vagina is again cleansed. 
With stout, blunt traction forceps, the uterus is pulled down, and 
the point at which the vagina is reflected from the cervix is demon- 
strated by moving the cervix up and down in the vaginal vault. 
This point of reflection is shown by a crescentic fold which appears 
just behind the cervix when the cervix is shoved up (Fig. 268). 

Picking up this fold in the middle with strong mouse-tooth for- 
ceps, the operator cuts through the vaginal mucous membrane. This 
incision is extended to each side, making a cut about an inch. long. 
The scissors cut through the vaginal mucosa only. The posterior 



PEL VIC INFLAMMA TION. 
Fig. 270. 



469 




The index fingers are inserted into the opening in the cul-de-sac, and the incision is enlarged by blunt 
tearing with the fingers. (From life.) 

flap is now grasped at its centre by stout forceps, and while making 
down-traction upon the uterus and this flap, the operator pushes his 



Fig. 271. 




The uterus is held up behind the symphysis (S) with the bladder (B) by the trowel (X), while the rectum 
(J?) and the posterior vaginal wall are pulled down by the retractor (Y). 

finger into the cul-de-sac up to the level of the internal os (Fig. 
269). 



470 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



If the finger has not already perforated the peritoneum, the 
cavity is wiped dry and the peritoneum picked up with forceps and 
cut with scissors. A digital examination of the pelvic contents is 



Fig. 272. 




The cul-de-sac is opened. The posterior vaginal wall is held down by the retractor, while with the trowel 

the uterus is shoved upagainst lln- bladder. The space obtained is estimated by comparing the length 
of the operator's index linger with the distance between the blades of the retractors. In this case it 
was 2% inches. (From life.) 

now made, still keeping up down-traction on the uterus. Having 
satisfied himself that an ocular inspection is necessary, the operator 
introduces two fingers into the opening in the cul-de-sac, and, sepa- 
rating them laterally, he tears the vaginal mucous membrane and 
peritoneum (Fig. 270). Very rarely will the vaginal mucosa be 
found so stout that he cannot do this. Should it be so, he will 
lightly touch it with a scalpel in the direction in which he wishes 
the tissues to separate. The medium blade of the long Pean re- 
tractor is introduced into the pelvic cavity, the forceps on the pos- 
terior flap are removed, and the cervix is freed from the traction 
forceps. The Pean-Pryor trowel is now inserted into the pelvis 
and the uterus forced up behind the symphysis (Fig. 271). This 
will widely open up the pelvic cavity. Into this opening a gauze 
pad, to which is attached a stout string, is inserted to prevent de- 
scent of the intestines and to catch any sero-sanguineous fluid. 
The patient, still on the back and with legs bent upon the trunk, 



PELVIC INFLAMMATION. 



471 



is thrown into Trendelenberg's position (Fig. 272). By gentle man- 
ipulation with small gauze pads held by forceps the intestines and 
omentum are made to enter the abdominal cavity. When it is 
found that the intestines are adherent, they are gently freed. The 
whole pelvic cavity may now be readily inspected and the diagnosis 
is established. Even the vermiform appendix, if it be suspended 
in the pelvis, may be seen. The uterine appendages may be gently 

Fig 273. 




drawn into the incision and minutely inspected, and should any 
treatment be indicated which may be carried out through a vaginal 
incision, the operator is in a position to proceed at once with the 
proper manipulations. 

Having satisfactorily examined the pelvis, all fluid is wiped 
away, the uterus again washed out, and packed full of iodoform 
gauze. Everything is removed from the peritoneal cavity, and a 



472 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

loose plug of iodoform gauze is inserted just within the edges of the 
vaginal rent, which must fill the opening to prevent protrusion of 
small intestine. The uterus and this plug are replaced en masse 
and the vagina is filled with gauze. A self-retaining rubber cathe- 
ter is inserted into the bladder, and the sphincter ani dilated. On 
the third day the patient is put in Sims' position and the uterine 
packing removed without irrigation. Whatever vaginal gauze has 
been taken out to do this is replaced by fresh dressing. The cul- 
de-sac plug is left in for from seven to ten days, according to the 
character of the case. It is removed and replaced under a short 
chloroform narcosis. In doing this the patient is in Sims' position. 
The operator must be careful to support the cervix anteriorly with 
the trowel, so as not to disturb the lymph behind the uterus. A 
second dressing is made a week later, without pain, and repeated 
until the opening closes. The patient is allowed to sit up in bed 
after the first dressing, get out of bed in two weeks, and becomes an 
office case in from two to three weeks. The peritoneal cavity is 
entered in from one to five minutes. 

Prognosis. — The prognosis of pelvic inflammations is variable 
according to the phase which the disease assumes, the character of 
the infection, and the manner in which it is treated. It may end in 
complete recovery, permanent crippling, or death. Catarrhal sal- 
pingitis usually undergoes a spontaneous cure, at times with a com- 
plete restoration of the tissues to their normal condition of health, 
oftener after the destruction and desquamation of the ciliated epi- 
thelium. Should the Fallopian tubes become occluded at any point, 
sterility is an accomplished fact, and either a hydro- or hematosal- 
pinx a possibility. Even without occlusion of the Fallopian tube 
sterility is frequent, from the fact that the cilia, whose function it 
is to carry the ovum toward the uterine cavity, are lost, and the 
ovum may lodge at any point throughout the length of the tube, 
and there perish, or it may be so long delayed in its passage as to 
be too enfeebled to become impregnated when it meets the sperma- 
tozoid. Extra-uterine pregnancy is commonly accompanied by a 
history of long-standing sterility, and it is this disease which is 
supposed to be the cause of the misplaced conception. The ovum, 
lodging in the Fallopian tube, becomes impregnated by the sperma- 
tozoid, and, not being able to escape into the uterine cavity, develops 
in the tube. 

If the ends of the tube remain patulous, there is no great danger 



PELVIC INFLAMMATION. 473 

of an accumulation of the excretions, but should they become closed, 
a hydrosalpinx is almost inevitable, unless the excretions have 
ceased or the absorptive powers of the tube are equal to the occa- 
sion. Hydrosalpinx is not fraught with any great danger to life, 
and unless it becomes complicated by pelvic peritonitis is not liable 
to cause any great discomfort to the patient. It would act in much 
the same manner as would small unadherent ovaries. Should peri- 
tonitis supervene and adhesions result, the patient would suffer from 
long-continued pelvic distress and pains, and would be liable to sec- 
ondary attacks of peritonitis. Hematosalpinx acts in much the same 
manner, it being more liable to inflammatory complications. Inter- 
stitial salpingitis always threatens life, for the reason that it is always 
complicated by pelvic peritonitis. The affected Fallopian tube is 
always occluded, either throughout its course or at its distal end, by 
the fimbria becoming adherent to the ovary. If both tubes are so 
affected, sterility is certain and permanent. The amount of danger 
to life will depend in great part upon the amount of the complicat- 
ing peritonitis and cellulitis. If the infection has been a particu- 
larly virulent one, and has escaped out of the fimbriated end of the 
Fallopian tube before Nature has had an opportunity to build up a 
wall of obstructing lymph, it will probably infect the larger part of 
the pelvic cavity before its course can be stayed : should it escape 
into the abdominal cavity, a general peritonitis is likely to result, 
and death follow. Puerperal septic infection is more liable to have 
this termination than gonorrheal infection, although the latter claims 
its fair share of victims. Women who have acquired interstitial sal- 
pingitis, and in whom the disease has become chronic, are very liable 
to suffer from recurrent attacks of peritonitis. These attacks occur 
more or less frequently and with more or less severity. At any 
time they may develop into a general peritonitis and end fatally, or 
suppurative changes may be set up which will require a surgical 
operation to save the patient's life. So long as they remain qui- 
escent they cause little more damage than that brought about by the 
constant pain. On the other hand, they may render the patient's 
life miserable, the only prospect of relief being either their removal 
or the menopause. It is an undoubted fact that the change of life, 
when it becomes established, brings relief and cure to many of these 
women : the disease, however, frequently accompanies delayed men- 
opause, and is most probably the cause of the delay. Spontaneous 
cures other than by the menopause are rare ; at the same time, it 



474 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

cannot "be successfully disputed that such is the case in a small pro- 
portion of cases. 

Pyosalpinx and ovarian abscess are much more liable to be accom- 
panied with recurrent attacks of peritonitis, and are consequently 
more serious lesions, than any of the other forms of disease of the 
uterine appendages. Usually they mean lifelong invalidism to the 
patient if she escapes primary death. Death is often the least 
of the consequences of this lesion. The patient drags along in a 
miserable condition of sepsis, with its resulting fever, hectic, and 
emaciation, until she dies of exhaustion or until the abscess has 
succeeded in finding an outlet into some of the neighboring vis- 
cera : even then her last state is hardly better than her first. 
Should the rupture occur into the uterus, a spontaneous cure may 
result, or the tube may refill and discharge repeatedly, all the while 
with the chance of its calibre becoming permanently closed. Should 
leakage take place from the fimbriated end into the peritoneal cav- 
ity, a general suppurative peritonitis may result, with its usual end- 
ing. Should, on the other hand, the pus find its way through the 
bowel or bladder-walls, a sinus will be formed which will most prob- 
ably refuse to yield to any treatment short of surgical. This disease, 
at the best, means a lifelong invalidism to the patient, and is a con- 
stant menace to her life. Much the same may be said of abscesses 
in the pelvis due to peritonitis and cellulitis. Those occurring pri- 
marily in the cellular tissue, following labor, are said to run a rapid 
course, and generally end in death, unless they are recognized and 
provision made for the discharge of the pus. Even with this pre- 
caution many cases die. The same may be said to be true in a less- 
ened degree of ordinary pelvic abscesses, although this form is apt 
to give sufficient time in which the physician may act. If these 
abscesses are properly opened and drained, the chances for the 
patient's recovery are good. Should they be neglected, the woman 
will either die from the exhaustion of septicemia, or the abscesses 
will open spontaneously in one of the many ways already described. 
Frequently it is impossible to obtain healing of the sinus tracks 
made by the burrowing of the pus from these abscesses, and, in 
spite of the fact that the abscess-cavity is emptied, the purulent 
discharge continues indefinitely, the patient eking out a miserable, 
lingering existence, only to die finally of exhaustion. 

Treatment. — The treatment of pelvic inflammation is satis- 
factory in accordance with the stage of the disease and the manner 



PELVIC INFLAMMATION. 475 

in which it is attacked. It is one of the preventable diseases, and if 
the infection is taken in hand in time it is perfectly amenable to treat- 
ment. After it has gained full headway it is only possible to amelior- 
ate the symptoms, and finally, if necessary, to remove the resulting 
lesions. The treatment is prophylactic, palliative, and curative. 

The prevention is embraced in the treatment and cure of the 
infection while it is still confined to the vagina and to the uterus. 
If the vaginitis or endometritis be taken in time, the disease may 
readily be stayed and a pelvic involvement prevented. This is 
true of the majority of cases, but it must be borne in mind that 
there is a certain proportion, of puerperal patients particularly, in 
whom the infection travels so rapidly that the serous membrane is 
involved before the physician has time to realize that the danger is 
seriously threatened ; this is also true of a small proportion of 
gonorrheal cases. In spite of the existence of these exceptional 
cases, it is a lamentable fact that the majority of pelvic inflamma- 
tions are preventable, and that the attending physician is only 
too frequently responsible — if not for sins of commission, at least 
for sins of omission. If a patient be suffering from gonorrhea, 
it should always be attacked vigorously and scientifically, ever 
bearing in mind that the mildest case may result in irreparable 
damage to the pelvic peritoneum, and may even result in death. 
The vagina must be exposed throughout its whole extent and 
thoroughly treated, and, if the endometrium becomes involved, 
it should receive equally prompt attention. The methods of 
treatment of these troubles will be found fully expounded in the 
chapter on Inflammatory Diseases of the Uterus. Infection start- 
ing in the uterus from a post-puerperal sepsis should never 
be neglected. General treatment as it is too often indulged 
in by the physician is only playing with fire, and, like the pro- 
verbial child, his fingers are frequently burned. Every woman 
who after a labor or a miscarriage has an elevation of temper- 
ature and pulse, together with discharges which smell badly, 
provided conditions other than sepsis are excluded, should at 
once have an antiseptic vaginal douche. Should the tempera- 
ture and pulse not fall to normal or thereabouts after several such 
douches repeated at half a dozen hours' interval, the syringe should 
be carried to the fundus of the uterus and a similar injection made 
into the cavity of the womb. If after repeating this treatment sev- 
eral times in the twenty-four hours the patient's symptoms have not 



476 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

subsided or become markedly better, the physician is committing an 
inexcusable blunder if lie does not thoroughly curette the whole of 
the cavity of the womb, irrigate it, and render it as aseptic as pos- 
sible. Should all cases of gonorrhea and puerperal sepsis be treated 
on these common-sense principles, pelvic inflammations in women 
would be far rarer than they are at the present time. To just the 
extent of intelligence with which the physician treats these cases will 
he have the fewer cases of pelvic trouble originating in his practice. 
Should the disease once invade the Fallopian tubes, it is beyond 
local treatment, and it is largely a matter of chance as to how far 
it will spread and how much damage it will succeed in doing before 
being brought under control. In Nature's hands lie the most 
effective weapons for combating the inflammation, and practically 
all the physician is able to do is to aid by placing the patient under 
the most favorable circumstances possible and giving Nature every 
chance to succeed in her fight. In the acute form of the disease 
two objects must constantly be kept in mind: the force of the 
inflammation must be weakened in every possible way, and Nature 
must be left unhampered to wage the fight. As in every inflamma- 
tion, rest is absolutely essential. By " rest " is meant sexual as well 
as physical quietude. The woman should be placed in bed, and 
kept there until the attack has subsided : sexual intercourse should 
not only absolutely be prohibited, but even the approach of the 
husband, sufficient to excite pelvic congestion, must carefully be 
guarded against. Many an attack of threatened pelvic inflamma- 
tion has been precipitated by indiscretions in these directions. 
During the menstrual periods the greatest caution is necessary. 
The congestion incident to this period is physiological, but in a 
patient who is threatened with a pelvic inflammation, or in one in 
whom the inflammation is actually in existence, it may readily be 
converted into a pathological state and the inflammatory attack be 
precipitated. Rest cannot be obtained perfectly if the bowels, espe- 
cially the sigmoid flexure and rectum, are allowed to become over- 
loaded with fecal matter. The hard, scybalous masses which form 
under these circumstances are a continual source of irritation. 
Woman is naturally a constipated animal, but these masses are the 
more apt to form, inasmuch as the peristaltic action of the bowel is 
in great part inhibited by the inflammation of its serous coat. It 
becomes a matter of prime importance, then, to empty and keep 
the lower bowel free from accumulations of fecal matter. Absolute 



PELVIC INFLAMMATION. 477 

rest having been secured, depletion is next to be obtained. The 
intestinal tract is the most adapted of all sources for bringing about 
this result. The free use of some drastic purgative will best con- 
serve the purpose. Possibly some one of the magnesium salts is the 
best drug for this use. Magnesium sulphate, administered in doses 
of a teaspoonful, dissolved in a small quantity of water, a saturated 
solution being preferable, each hour, for from six to ten doses, will 
usually produce the desired result. Should the salts be rejected, as 
they sometimes are, any other purgative may be substituted. The 
bowel will incidentally be emptied of its fecal contents, and large and 
repeated watery stools will result. The amount of damage done by 
friction set up by the peristaltic action of the intestines will be far 
outweighed by the good done by the general and local depletion. 
The watery stools are produced by drawing on the fluid element in 
the blood-vessels from all over the body, but particularly from those 
near and connected with the intestinal tract. The withdrawal of 
this fluid lessens the blood-supply to the inflamed parts, and at the 
same time creates such an intense demand for fluid in the vascular 
system that the inflammatory exudates are taken up the quicker. 
A pelvic inflammation which is just starting is often cut short by 
this procedure, and it is at times surprising to see the amount of 
relief experienced by patients, as demonstrated by the cessation of 
pain and the absence of the anxious expression of the countenance. 
One free movement of the bowels will in some cases act more 
promptly in this direction than will several hypodermics of mor- 
phia. There are certain cases, however — usually those who have 
been suffering for some time before having come under treatment — 
whom the treatment will not relieve, it matters not how many times 
the bowels are moved. Inflammations in the pelvis are like inflam- 
mations in any other part of the body: if depletion is not applied 
until the trouble is chronic, there is little to be expected from it; in 
the acute stage it is invaluable. 

It is not possible to keep up purgation indefinitely, and especially 
if the patient be not particularly strong, care and discretion must be 
used in this direction. It is well, if the woman can stand it — and 
the vast majority of them are able to do so — to procure one good 
purgation consisting of six to ten free watery stools. After this the 
bowels may be kept soluble daily by administering a laxative once 
in the twenty-four hours. After purgation hot vaginal douching is 
perhaps the best method of securing continued depletion of the pel- 



478 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

vis. If the douches be given properly, they will go a long way 
toward effecting a speedy reduction of the inflammation ; if they 
are given improperly, they will only render matters more compli- 
cated. Douches as usually employed by the profession at large were 
far better done away with altogether, as they only tend to render 
the pelvic inflammation worse. The primary effect of the applica- 
tion of hot water is to cause a congestion and the determination of 
large quantities of blood to the parts, as any one can demonstrate 
for himself by placing his hands in hot water and noting how puffy 
they become. If the water be sufficiently hot and the hand be 
held in it long enough, the tissues will begin to shrink, and what 
is commonly known as the "washerwoman's hands" will be the 
result. This condition is brought about by the secondary action of 
the hot water ; that is, contraction of the soft tissues. This con- 
traction renders the calibre of the blood-vessels smaller, and drives 
a very considerable proportion of the blood out of the parts so 
affected. The more profoundly this action is produced and the 
longer it is kept up, the more complete and lasting will be the 
depletion. It is this secondary effect of the hot water that it is 
desirable to produce in the pelvis. The more thoroughly the blood 
is driven away from the parts, the sooner will the inflammation 
subside ; the more frequently the action is brought about, the sooner 
will the blood-vessels acquire sufficient tone to limit the amount of 
blood they will hold and its powers of exudation. For the success- 
ful accomplishment of this object there are a few rules which it is 
imperative to keep in mind and carry out: The water must be hot, 
from 100° to 110° F., and to be sure that it is of this temperature 
a thermometer should be used. The water must be of sufficient 
quantity to produce the desired secondary action ; for this purpose 
at least a gallon should be used at each injection. It must be 
applied directly and continuously to the parts to be affected ; for 
this purpose the patient should lie in the recumbent dorsal position 
while the douche is being administered. It is important that this 
rule be observed, for the reason that should the woman assume 
a crouching or sitting position all of the water runs away as quickly 
as it is injected, barely coming in contact with the vaginal vault, 
the very part which it is desirable to reach. With the woman 
lying flat upon her back and the knees drawn up, the posterior 
portion of the vagina will be distended with water, and there will 
always be a residual amount in situ, which is constantly bathing 



PELVIC INFLAMMATION. 479 

tli e parts and is kept at the proper temperature by the continued 
injection. The douche should occupy from fifteen to twenty 
minutes in its application, and can best be taken in the bath-tub, 
if the patient is able to be up and about, and is forced to use it 
without the aid of a second person. The syringe, of whatever 
kind used, must have a hard-rubber nozzle, as metal, being a good 
conductor of heat, will burn the parts if the water is used as hot 
as is needed. These douches may be administered two or three 
times a day, and may be continued for an unlimited time, depend- 
ing on their effect and the way in which the patient progresses ; but 
in beginning them, it must be remembered that they are apt 
to cause a patient to feel exhausted ; in fact, a patient is occasion- 
ally found not to be able to use them at all on this account. 

Depletion may be obtained with advantage in certain cases by 
direct bloodletting. A free scarification of the cervix will not 
infrequently, early in the acute cases, give an immense amount of 
relief, and may even materially limit the extent and severity of the 
attack. This aid in the treatment is much neglected at the present 
day, but it will at suitable periods in an attack of pelvic inflamma- 
tion be found of great service. If the treatment is attempted, it 
should be done in a thorough manner. The cervix uteri is to be 
well exposed by the aid of a speculum, and deeply punctured at 
a number of points, so as to cause free bleeding. Ten or fifteen 
punctures are none too many, and from three to six ounces of blood 
will not be too much to withdraw ; it will, in fact, be difficult to 
obtain so much. It may be desirable to have the depletion con- 
tinue for some little time, and if a light glycerin tampon will not aid 
the actual flow of blood, it will withdraw a portion of the watery 
element from the surrounding tissues, and thus in a mild way con- 
tribute its aid toward a continued depletion. It is not advisable 
or necessary to use all these methods of depletion in every case of 
pelvic peritonitis : they are the best methods at our command, and 
must be used with judgment as the indications for them arise in 
particular cases. In the acute form of the disease, when there is 
considerable induration, it has been proposed that an aspirating 
needle be thrust into the mass through the vaginal vault and the 
serous exudates drawn away. It is claimed that the depletion thus ob- 
tained will end the attack in a very short time. The amount of good 
derived by this measure will not be commensurate with the risks of 
carrying infection on the needle and thus causing suppuration. 



480 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

Should the pain become so great as to be unbearable before the 
inflammation has subsided sufficiently to give relief, it is eminently 
proper to administer an opiate for its temporary action. It is well 
to remember that opium in any form depresses the heart, lessens 
the excretive and absorptive powers of the tissues, and inhibits 
peristaltic action of the bowels, all of which effects are contra- 
indicated in these diseases. It is exceedingly desirable that excre- 
tion and absorption should be free and that the bowels should remain 
soluble. For these reasons, if it becomes necessary to use an opiate 
— and it should only be used if absolutely necessary — that form 
is to be selected which will cause the least harm, and it is to be 
administered in as small quantities at as long intervals as is com- 
patible with obtaining the effect desired. Morphia, used hypo- 
dermically, is least objectionable of all the forms of opium. Fre- 
quently one dose of an eighth of a grain is sufficient, but it may be 
necessary to repeat it at intervals of five or six hours for several 
doses. One injection of morphia in this dose will often relieve the 
patient of her intense pain until a movement of the bowels can be 
secured, when, as a rule, there will be no necessity for its repetition. 
The one dose can do no possible harm ; it does not even delay secur- 
ing the desired movement of the bowels. 

Counter-irritants are not of any great importance in the acute 
form of the disease, but when it has assumed more of a subacute or 
chronic condition, they have their uses. Iodine applied freely to the 
vaginal vault and over the lower part of the abdomen once a day will 
give a certain amount of relief; whether it be actual or imaginary 
matters little ; it can do no possible harm, and at least gives the com- 
fort of the knowledge that something is being done. While not a great 
deal of reliance can be placed upon it, yet it is occasionally a matter 
of difficulty to explain the apparent cause and effect between the ap- 
plication of the treatment and the resulting relief. It is so uniformly 
used in conjunction with other treatment that it is sometimes hard 
to say whether or not it accomplishes good. Turpentine stupes and 
poultices to the abdomen do no harm and little good ; what good 
they do accomplish is incidentally through the heat which accom- 
panies their application, and is more mental than real : the good 
derived from blisters is hardly sufficient to counterbalance the 
amount of suffering they cause. These are all remedies which are 
very generally used, and serve as well as anything else to keep the 
patient satisfied that every possible thing is being done for her. 



PELVIC INFLAMMATION. 481 

Little or no attention need be paid to the pnlse and temperature, 
other than to watch them closely in order to note the progress of the 
disease. They are symptoms which will take care of themselves, 
and never call for any especial treatment: they will fluctuate with 
the inflammation, but seldom rise sufficiently high, or remain high 
long enough, to cause any organic changes in the tissues, unless pus 
be present. Under any circumstances the disease is to be treated, 
and not its symptoms. Antipyretics are never indicated, and only 
when sepsis arises are heart-stimulants called for. Diuretics and 
diaphoretics would have their places for purposes of depletion were 
there not much more prompt and efficient means at our disposal. 
Diet and drink are both important elements in the treatment. The 
diet should be light, but nourishing — of such a character as to make 
as little fecal matter as possible, at the same time not to furnish an 
excess of fluid. It is well for the first few days of the attack that 
fluid should be withheld as much as possible, so that the inflamma- 
tory excretions may the more quickly be absorbed. The patient 
should be kept confined to bed until all pain and local tenderness 
has disappeared. If this line of treatment 
be carried out systematically and carefully, ^gB^^ 

there is a chance in a certain proportion of § ^^\ 

cases that a permanent cure may result and %^ ^^m 

the parts be restored to a fair condition of " rfv *^_ y „--'' A 
functional health. j 

Should this treatment fail to stay the i 

acute disease, posterior vaginal incision, as The cui-de-sac incision is made 

1 from A to A. If more room is 

suggested by Henrotin, may accomplish the ^w^l b me n dfti^f the 
result. The procedure is accompanied by vagina from y t0 x - 
little danger. The object is to open the connective-tissue spaces 
about the uterus, and, after breaking up adhesions and penetrating 
any masses of exudate met with, to drain the resulting cavities. 
The operation consists in making an incision, moderately circular, 
close to or rather slightly on the posterior surface of the cervix, and 
to dissect back the vaginal mucosa through the cellular tissue to a 
point beyond which the wounding of the uterine artery seems im- 
probable. The incision never extends beyond the outer limits of 
the cervix. If necessary, more room may be gained by joining this 
incision with another one running directly backward in the median 
raphe of the vagina, care being taken not to penetrate sufficiently 
deep to wound the rectum. With the exception of the incision 



482 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

through the vaginal mucosa, all manipulations are made with the 
finger exclusively. The disengaged hand being placed upon the 
abdomen, the operator proceeds as in making a bimanual palpation, 
and with the index finger of the vaginal hand gradually penetrates 
the tissues in the direction of the centre of the affected region, 
whether this be laterally in the broad ligaments or posteriorly in 
the peritoneal cavity. All exudates are penetrated, all adhesions 
are broken up, and free drainage established. The cavities entered 
are packed loosely with sterile gauze, the free ends of which are 
left hanging in the vagina. The whole vagina is loosely packed 
with gauze. The dressing is removed only after three or four days, 
at which time the cavities are gently irrigated and the packing 
renewed. This is repeated several times at two days' intervals, after 
which merely a daily vaginal douche is required. The operation 
takes from five to ten minutes only. 

Frequently, in spite of the most careful treatment, the result will 
only be a relative one, and although the inflammation may subside 
after weeks' or even several months' treatment, yet masses of the ex- 
uded lymph, together with the disorganized Fallopian tube, remain, 
and the inflammation may be relighted at any time, when the whole 
treatment will have to be gone through with again. In certain 
cases the inflammation never entirely subsides, but the woman is a 
constant sufferer from pelvic pain and discharges. She eats little, 
sleeps badly, and coitus is more or less painful, as is also walking or 
jolting of any kind. Such patients will apply for relief after years 
of constant suffering. An examination will disclose a condition of 
insterstitial salpingitis, masses of unabsorbed exudates, and a ten- 
der pelvis. The woman is able to be on her feet attending to her 
daily work, but is often a wreck of her former self. It is possible 
in many of these women to greatly improve their condition, pro- 
vided pus is not present in the pelvis. Their relief naturally will 
only be tentative, for as long as the exudates and diseased append- 
ages remain, they are liable under favorable circumstances to a return 
of all their aches and pains. The object to be aimed at in the treat- 
ment of these cases will be to bring about an absorption of the in- 
flammatory exudates and to accomplish a subsidence of the inflam- 
mation. In these women rest, especially sexual rest, is essential to 
success. The only sure way of accomplishing this is by separat- 
ing husband and wife, so that there may be no temptation : for this 
reason, where it is possible, a hospital is the best place to carry 



PELVIC INFLAMMATION. 483 

out the treatment. When this is not possible, tamponing is quite 
effectual — in fact, is the only safeguard. The patient must be 
guarded as much as possible from over-exercise, especially the use 
of sewing- or similar machines. The clothing must be warm 
and dry, and all exposures to cold carefully avoided. The 
bowels should be kept soluble, and an occasional purgation for its 
depleting effect is indicated. Depletion may be obtained also by 
the use of the hot- water injections, as in the acute form of inflam- 
mation, but to result in any good it will be necessary to use them 
systematically and for a long period of time : they should be used 
once or twice daily for months. Glycerin tampons, alternating 
with counter-irritation over the whole vaginal vault by painting 
with iodine, are of service if properly used. In fact, the tampon 
can be utilized, after the parts have been painted with iodine, with 
advantage. Dry tampons are frequently serviceable, even aside 
from their use in preventing coitus. The weight of a heavy and 
engorged uterus, retro-displaced, dragging upon tender and adhe- 
rent ovaries, together with any movement of the pelvic organs 
caused by walking or riding, is a constant source of distress, pain, 
and backache. If the patient be placed in the knee-chest, or even 
the lateral position, and the whole pelvic mass of diseased and adhe- 
rent organs be allowed to gravitate toward the abdominal cavity, a 
tampon of some soft yielding material can be so placed as to fill the 
whole of the vagina, or even the posterior portion of it, care being 
taken not to pack it hard enough to cause trouble by its pressure. 
When the patient stands on her feet the pelvic organs gravitate 
back again toward their former position, but the tampon now re- 
ceives their weight and holds them somewhat above their former 
level, if only for a fraction of an inch — sufficient at least to take 
the drag off the adhesions. In a certain class of cases the relief 
obtained from this procedure is remarkable. It is essential that the 
tampon be of some soft, elastic, unabsorbable material, and that it 
be placed so as not to make too much pressure. Surgical cotton 
absorbs moisture, loses its elasticity in a few hours, and becomes a 
hard foreign body in the vagina. In addition, it shrinks, so that it 
loses its effect so far as giving support is concerned. Wool is the 
best material for this use. The tampon is much superior to a pes- 
sary for accomplishing this end. But the fact that a pessary at 
times gives relief to the patient suffering from pelvic inflammatory 
disease is only explainable in this way. In spite of the fact that 



484 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

a. Smith-Hodge pessary will give relief in some few cases, it is a 
dangerous instrument to use in this disease. If an ovary is pro- 
lapsed, the pressure of the hard pessary will render its use unbear- 
able from the pain it causes. Should a fall or jar occur while the 
pessary is in situ, it might readily transmit so much of a blow as 
to light up a latent inflammation or to rupture a cystic tube or 
ovary. A tampon is preferable in every way, and it may be put 
down as a good and safe rule that a pessary should never be em- 
ployed in the presence of pelvic inflammation. Tampons, when 
used, should be removed at least every other day, and the vagina 
thoroughly cleansed and dried before a second one is introduced. 
If the tampon is thoroughly impregnated with some dry powder, 
such as boracic acid, it will keep sweet and clean the longer. 

Where the application of iodine and glycerin has failed to relieve 
the pelvic pains and tenderness, ichthyol has been used. Ichthyol, 
either in its pure state or mixed with glycerin in equal parts, 
and applied on a tampon to the vaginal vault, has succeeded in 
relieving the tenderness in some cases when everything else has 
failed. These applications in order to accomplish any good must 
be made at least twice a week for the course of several months 
or more. 

General medication accomplishes nothing directly ; although 
potash, mercury, and other remedies have been lauded for their 
specific effect, there is no drug which, given internally, will have 
the slightest effect upon the inflammation or its products. The 
absorption of the infiltrates and exudates will greatly be aided as 
the condition of health of the patient is good or bad, and every 
effort should be made to build up the general health to as nearly 
a normal condition as possible. General tonics and alteratives, 
combined with a proper regulation of the bodily functions, a well- 
ordered diet, limited but healthful exercise, and slight stimulation 
when indicated, is the proper course of general treatment to follow. 
It aids in the cure simply by placing the tissues of the body in 
a favorable condition for performing their work, and by giving 
Nature a chance to rid the parts of the inflammation and its 
products. 

Many of these patients are very much run down and have lost 
a considerable amount of flesh : they consequently need building 
up. Amongst other remedies for this purpose, electricity and 
massage have their place. General galvanism given daily for its 



PELVIC INFLAMMATION. 485 

tonic and stimulating effect, together with general massage, is 
indicated. It is not necessary to submit the patient, as a general 
thing, to a strict course of " rest treatment," as the good effects of 
this method may be obtained by a very material modification, and 
the woman may be up and about, attending to a moderate amount 
of work, sufficient to keep her body and mind occupied, without 
allowing herself to become over-fatigued. Electricity applied 
locally to the pelvis is of very indefinite value. In the acute 
attack of inflammation it has no place, and its use can only result 
in harm. When the force of the inflammation has subsided and 
it has settled itself down into a subacute or chronic condition, 
electricity may at times be used with advantage. It will occasion- 
ally relieve the symptoms of pain and uterine hemorrhage when 
other remedies have failed, and, on the other hand, it will often 
fail to give relief to these symptoms ; in fact, it will render them 
worse, when other remedies will bring about the desired effect. 
The relief obtained from this remedy is, like all others, merely 
temporary : it never cures the lesion, it simply relieves the symp- 
toms, and, the disease being still present, the symptoms are liable 
at any time, under favorable circumstances, to return. It is claimed 
for electricity by its votaries that large pelvic inflammatory masses 
will shrink and disappear under its use. Such is in truth the case, 
but when we consider of what these masses are composed, it is easy 
to see why the remedy has been of service in causing them to dis- 
appear. They would have disappeared under any other proper 
method of treatment as well. In an acute attack of peritonitis great 
quantities of lymph are thrown about the diseased tubes and ovaries, 
forming large masses, which on palpation through the vaginal vault 
give an idea of size to the tube and ovary which is out of nil pro- 
portion to their real size, the bulk of the tumor being made up of 
lymph-exudate, and, at times, exudates into the connective 
tissue. As the inflammation subsides, Nature causes an absorp- 
tion of these exudates to a great extent, with the result that the 
pelvic mass gradually diminishes until nothing but the adhe- 
rent tube and ovary remain ; the appendage at times is quite 
small. In fact, the case under these circumstances has now as- 
sumed the chronic form of adherent interstitial salpingitis. It is 
this natural function of absorption which electricity stimulates and 
aids — nothing more, nothing less. In addition, the soothing effect 
of the galvanic current gives in a certain proportion of cases great 



486 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

relief to the pain, while the uterine contraction induced by the 
stimulation of the uterine muscle, together with the direct effect of 
the cauterization upon the endometrium if sufficient current be ap- 
plied, gradually lessens the amount of blood lost. As an aid in the 
treatment of cases of subacute or chronic pelvic inflammation the 
procedure is valuable : it is to be regarded as an additional remedy, 
only one of many, to be used as simpler and easier forms of treat- 
ment fail or are slow of accomplishing their object. In using this 
remedy the galvanic negative current should be selected, and the 
application may be made either intra-uterine or intra-vaginal, the 
latter being the safer. Where it is desirable to aid Nature in 
absorbing exudates and relieving pain, the current should not be 
stronger than the patient is able to bear without much pain ; the 
application is to last but a short time, and is to be repeated two or 
three times a week. A good average application of the galvano- 
negative current, and one which is usually well borne, is in the 
neighborhood of fifty milliamperes applied for about three minutes. 
When the hemorrhage is excessive, it is better to use the positive 
pole, and the application should be made intra-uterine. Weaker 
currents, twenty to thirty milliamperes, are to be used where the 
galvano-positive current is selected, for the reason that this is much 
more painful than the galvano-negative and is not so readily borne 
by the patient. Even though the current is not sufficiently strong 
to cauterize the lining mucous membrane of the uterus, yet the posi- 
tive pole coagulates the albuminoids of the tissues and causes con- 
traction of the uterine muscles, in this way lessening uterine hem- 
orrhage, and cutting off the blood-supply. It is only by its judic- 
ious and careful employment that any good can be obtained from 
the use of electricity : the careless or ignorant use of it may read- 
ily do more harm than good. It is essentially a remedy the use 
of which will for the most part remain in the hands of the special- 
ist ; it is of little use to the busy general practitioner, as the appa- 
ratus is complicated and expensive, and very considerable time and 
care must be spent in the application. 

Massage has a much more limited use in pelvic inflammatory 
lesions, and is more dangerous in unskilled hands. It requires no 
especial apparatus. In the acute stages of the disease it has no 
place whatever, but its greatest use is in the chronic form, where 
there is a considerable quantity of unabsorbed exudate and lymph. 
The manipulations of the masseur act as exercise to the parts and 



PELVIC INFLAMMATION. 487 

stimulate absorption. Under careful and very gentle movements 
it can readily be seen why in this way pelvic masses disappear or 
become smaller. Its use is decidedly objectionable even in this 
class of cases, for the reason that it is impossible to say whether 
or no there be pus in the midst of the mass. Many a Fallopian 
tube which is not much larger than normal contains pus or puru- 
lent material. The application of friction, pressure, or kneading in 
such a case may readily result in the leakage of some of the tubal 
contents into the abdominal cavity : even were there is no purulent 
matter present, the manipulation might very easily relight a sub- 
acute or chronic inflammation into an acute attack. It is claimed 
for the treatment that the pus from a pus-tube may be caused to 
escape into the uterine cavity and a cure thus be effected : it is 
much more likely that the pus would first escape through the fim- 
briated ends of the tubes or rupture take place in the walls of the 
abscess. In addition to the dangers attached to its use, its applica- 
tion is very painful unless the greatest care or the most delicate 
touch is employed. Even then some cases are for a long time 
intolerant of the necessary handling of the parts. The treatment 
is altogether too dangerous for the general practitioner to employ, 
and its use will always be confined to the hands of the few. Mas- 
sage in these diseases consists in kneading the pelvic masses and 
applying friction to them to cause their absorption, and in moving 
the uterus in different directions to stretch and free its adhesions. 
The manipulation is carried out with one hand pressing through 
the abdominal wall and one or two fingers of the second hand in 
the vagina. The vaginal fingers are used mostly for lifting up and 
fixing the uterus or pelvic masses ; the manipulations are carried 
on in great part by the abdominal hand. The reverse is true, 
however, in exceptional cases. 

When suppuration has accompanied an attack of pelvic inflam- 
mation, the treatment which has been detailed, and which is appli- 
cable to some cases of the disease in its non-suppurative and 
non-cystic forms, is not to be considered. In these cases all the 
symptoms of septicemia are added to those which accompany the 
inflammation, and frequently the patient's life is threatened, if not 
immediately, at least remotely and constantly. Should the pus be 
confined to the Fallopian tubes, Nature occasionally relieves the 
danger by allowing it to escape into the uterine cavity. It has 
been proposed to take the hint from Nature as to the method of 



488 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



treating pus-tubes, and accordingly the treatment of aspirating 
the Fallopian tubes by passing an instrument into the uterus, and 
thence into the tube through its occluded uterine opening, has been 
advocated. Could the procedure be carried out with any degree of 
safety and certainty, it would offer a method of cure in a certain 
proportion of cases which would at times be satisfactory, and at the 
same time not be attended with the dangers of abdominal section. 
The objection to the treatment which should condemn it to oblivion 
is the uncertainty, nay almost impossibility, of passing the instru- 
ment. The catheter or probe, whichever it be, is of necessity small 
in diameter — so small that it would be just as liable to perforate the 
diseased and softened uterine wall as the occluded opening in the 
tube, even if the point which that opening occupied could be found : 




Drainage of Pelvic Abscess from the Vagina. 

the manipulations necessary to accomplish the operation would be 
attended with so much traumatism and movement of the diseased 
parts that the inflammatory process might very readily be relighted 
or an abscess-cavity ruptured. If for no other reasons, the treatment 
should be utterly condemned ; but pelvic abscesses are so notori- 
ously multiple that the mere emptying of one of these pockets of pus 
would have no effect on those remaining, and there would be no 



PELVIC INFLAMMATION. 489 

possible way of assuring one's self that some accumulation did not 
remain behind, it matters little how many had been drained. Where 
pus exists in the pelvis, there is but one treatment to be considered : 
evacuation by a surgical operation. A pelvic abscess should never 
be given an opportunity to evacuate itself. There is a point of elec- 
tion for the opening which, if left to Nature, will rarely be chosen. 
When pus exists, it should be evacuated at once ; delay is unjusti- 
fiable, either for building up the patient or for any other reason. 
The patient will not improve as long as she is continuously absorb- 
ing septic matter, and the longer the delay the worse will be her 
condition for operation. If the abscess be an accumulation of pus 
within the pelvis independent of the Fallopian tube or ovary, be it 
either altogether intra-peritoneal or involving the cellular tissue, it 
is best to evacuate it without opening the general peritoneal cavity : 
the vagina is the one point at which this is feasible and proper. 
Even in those exceptional cases where the abscess has risen into 
the abdominal cavity, and it is possible to open it above the pubis 
without entering the general peritoneal cavity, the vagina offers the 

Fig. 276. 




opening into the Bowel. Opening obliquely above and below the level of the sac. 

better point of operation, as it gives just as good an opportunity for 
irrigation and a better one for drainage. This of course presup- 
poses that disease of the uterine appendages has been excluded — a 
diagnostic feat which is rarely accomplished. The opening should 
never be made in the rectum, as has been proposed, even though 
the abscess be pointing there. The abscess-cavity can neither be 



490 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

irrigated easily through the rectal opening, nor can fecal matter be 
prevented from entering into it. Even where the opening occurs 
into the rectum spontaneously, it is slow to close in cases in which 
it ever does so. Where the opening is higher than the sacs, it is 
practically impossible to prevent fecal matter from entering, in which 
case closure is hopeless. There is one almost insurmountable obstacle 
to this method of treating pelvic abscesses, barring exceptional cases. 
It is rare that one is able to say whether or not the ovary or Fallo- 
pian tube contains pus. Should either do so, a possible subsequent 
abdominal section would become necessary, and it would then be 
complicated by the fistulous opening, which is always serious and 
which might prove fatal. As a matter of fact, the cases of pelvic 
abscess without ovarian or tubal suppuration are rare, and the infer- 
ences are all in favor of there being involvement of these organs, 
especially when the etiology of the disease is taken into consider- 
ation. In view of these facts, the proper treatment of pelvic abscess- 
is usually by abdominal section, under which circumstances the parts 
can readily be explored, the exact pathological condition noted, 
and the appropriate treatment applied. The operation from above 
amounts to little more than opening an abscess, and the certainty of 
complete evacuation that it gives the operator and patient is a great 
desideratum. 

Where the pus is confined in the Fallopian tube or ovary it has 
baen recommended that vaginal puncture be practised for its evacua- 
tion. This method of treatment is so full of objection that it is best 
never to recommend it. Where vaginal puncture would probably be 
the better procedure for unskilled hands in a general pelvic abscess, 
especially one which required such immediate evacuation that a 
skilled operator could not be obtained, it is not the proper procedure 
in abscesses confined to the uterine appendages and the lymph imme- 
diately surrounding them. As has been already said, this variety of 
pelvic suppuration is rarely confined to one cavity, but consists of a 
number of small pockets, none of which communicates with the 
others. The Fallopian tube itself may contain as many as three 
distinct and separate pockets; the ovary forms a cavity of its own, 
and two or more pockets are often found in the lymph in which 
the Fallopian tube and ovary are buried. The chances of more 
than a partial evacuation of the pus being obtained would be very 
scanty indeed. This objection has been recognized even by the 
advocates of this method of treatment, and for the purpose of 



PEL VIC I NFL A JIM A TION. 



491 



overcoming 



lg the difficulty they have gone so far as to advise that 
the abdominal cavity be opened, the parts explored, the various ab- 
scesses located, and each punctured in turn from the vagina. If the 
abdominal cavity be opened, it would seem the height of folly not to 
complete the operation. But even with the abdomen opened it is at 



Fig. 277. 




Showing Multiple Abscess- 



,'ities in a case of Pyosalpinx, demonstrating the uselessness of the 
treatment of tapping and draining. 



times absolutely impossible to locate all the abscess-cavities before 
the parts are enucleated. Even in the few cases in which the pus 
could be thoroughly evacuated the broken-down abscess-sacs, cheesy 
Fallopian tubes and ovaries would remain behind to cause the 
patient a long chronic invalidism, should she ultimately recover. 
The best results which one could hope to obtain from this method 
of treatment would leave the patient in exactly the same con- 
dition as a woman who has suffered from a pelvic inflammation, 
and after its subsidence had been left in a condition of chronic in- 
terstitial salpingitis and ovaritis. She would ever after carry a dis- 
organized Fallopian tube and ovary, and would be liable to recur- 
ring attacks of pelvic inflammation, any one of which might result 
in suppuration or in death. Purulent salpingitis and ovaritis, unless 
they end in death in from a few days to a week, are chronic condi- 
tions, and give ample time to allow the physician to obtain com- 
petent assistance for performing an abdominal section. 



492 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

The treatment of those rare accumulations of pus within the pel- 
vis which are extraperitoneal, and which do not involve the uterine 
appendages, differs in no way, in its first steps at least, from the 
treatment of the intraperitoneal abscesses. It is impossible to make 
a diagnosis of this condition prior to an abdominal section. When 
the abdomen is opened and the abscess-walls are found to be mov- 
able enough to be brought into the abdominal incision, it is best to 
aspirate, empty the sac thoroughly, irrigate the cavity- with hot 
water, stitch, the opening in the sac to the abdominal incision, and 
place a drainage-tube into the cavity. 

Should it be found, as is usual, that the sac could not be brought 
sufficiently high to be stitched into the abdominal wound, a vaginal 
incision should be made, the pus evacuated, and the drainage estab- 
lished from below. Until the abdomen has been opened and the 
diagnosis established this treatment manifestly is improper unless 
involvement of the Fallopian tubes and ovaries can with rea- 
sonable certainty be excluded. Should it be thought desirable after 
the diagnosis has been established, a second incision could be made 
above Poupart's ligament and the abscess-cavity reached by dissect- 
ing down into the cellular tissue below the reflexion of the perito- 
neum, j3ushing the peritoneum forward, as in operations on the 
bladder or for ligating the iliac vessel, and in this manner reaching 
the accumulations. The vaginal opening, however, where possible, 
is to be preferred. 

The ultimate treatment of pelvic inflammation is abdominal sec- 
tion in those patients who do not fully recover from the primary 
attack, and are left with their uterine appendages so diseased and 
disorganized that the symptoms produced by their presence either 
threaten life or so disable the woman as to incapacitate her for her 
daily vocation, and render her life a burden. It matters little 
whether pus be present or not, as many women suffer more from 
chronic interstitial salpingitis than they would from pyosalpinx 
or ovarian abscess. It would be well in the case of many patients, 
where there is no pus, to first try the medicinal treatment already 
described, but in this we are forced to make a distinction between 
the poorer and better-class patients. It has often been objected that 
no such distinction should be made, but it is well known that a given 
amount of involvement and destruction in a woman who can afford 
to undergo the time, trouble, and expense of a necessary course of 
treatment will give little or no permanent trouble, where a similar 



PELVIC INFLAMMATION. 493 

involvement in the case of a woman who is not able to afford the 
treatment will render her life miserable and will give rise to recur- 
rent attacks of peritonitis, each one increasing the local condition 
and endangering the life of the sufferer. Even were they both to 
suffer the same amount, the rich woman can afford to go to bed and 
become a semi-invalid, while the same thing to the poor woman often 
means starvation for herself and children, or the poorhouse. Though 
the operation is a dangerous one, the physician is justified under 
such circumstances to counsel a poor woman to take the risks, with 
the chances of regaining her health and putting herself in a condi- 
tion to bear the burden of life, where he would probably hesitate 
to advise the well-to-do patient to undertake the operation — not, 
at least, without a long and thorough trial of the medicinal — if it 
may be so called — treatment. If a patient's symptoms can be con- 
siderably ameliorated by treatment, she will often prefer to bear the 
lesser ills of her condition, than what to her are the greater ills of 
a surgical procedure. Unless a woman is subject to recurrent attacks 
of peritonitis, the disease may be left in situ without any danger to 
life, provided always that pus be not present : in these cases it is 
simply a matter of comfort or discomfort with a patient. Many of 
them suffer so much pain that they will accept an operation as soon 
as it is proposed to them, it matters little what the risk is, while in 
the case of others the idea of an operation is so horrible that they 
will rather bear any amount of suffering than even consider the 
radical procedure. The question of operation is one which must be 
left for the patient's decision, the facts having been placed fairly 
before her. The dangers of an operation for pelvic inflammatory 
disease in the hands of trained gynecologists are not much greater 
than those which attend each severe recurring attack of peritonitis. 
It is not possible to say just what the death-rate amounts to, but an 
honest investigation would find it not much below 10 per cent, in 
the hands of the many. In the hands of a few it reaches a lower 
limit. The fact that the woman is having recurrent attacks of peri- 
tonitis is one of the strongest indications that an operation for the 
removal of the appendages is required. It is not possible to lay 
down any hard-and-fast rule by which one may be guided in 
deciding for or against an operation ; each patient presents her 
own individual peculiarities, which must be taken into considera- 
tion. It can only be said that so long as the diseased appendages 
remain in the pelvis the woman is not cured : she is only relieved 



494 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

for the time, and at any moment a new attack of inflammation may 
be lighted up and the original condition be reproduced. 

The Operation. — Abdominal section is the only method of remov- 
ing the uterine appendages in pelvic inflammatory diseases, whatever 
may be said of their removal by other methods for other conditions. 
Their removal by the vaginal operation is extremely difficult and in 
many cases would be impossible. The operation is divided into two 
stages: the opening of the abdominal cavity, and the removal of the 
appendages. The preliminary step, opening the abdominal cavity, is 
common to all abdominal operations, and will be found described 
in the chapter on Technique. There is no danger to be met with 
until the peritoneum is reached, and then only in case there is adhe- 
sion of the omentum or intestines. This fact can readily be deter- 
mined by picking up the peritoneum between two pairs of hemo- 
static forceps, and rolling it between the fingers. The merest nick 
will allow the air to rush in, when if the intestines are not adherent 
they will drop back into the abdominal cavity. If either the omen- 
tum or the intestines are adherent to the parietal peritoneum, they 
are to be separated carefully by gradually inserting the finger be- 
tween them. The omentum may be found adherent over the 
inlet of the pelvis and greatly thickened by inflammatory infil- 
trate. If such be the case, it must be freed gently with the 
fingers, care being taken not to tear the bladder or the adhe- 
rent loops of intestines. It is usually easy to begin at the lower 
edge of the omentum to free it, working upward from the pel- 
vis toward the umbilicus. When it is tightly adherent to the 
bladder and its lower border cannot clearly be defined, it is well 
at times to begin above and work down toward the pelvis. The 
finger should be passed high enough in the abdominal cavity to 
reach a point where the omentum is free; then, with the finger 
between it and the intestine, it can be separated with more safety 
than from below : if when the bladder is reached there is any 
uncertainty as to where that organ ends and the omentum begins, as 
is at times the case, the apron can be ligated and separated at a safe 
distance above the doubtful point. 

If when the omentum is loosened it is found that it is suf- 
ficiently torn to cause free bleeding, the oozing points should be 
caught up with a pair of hemostatic forceps and ligated. Should 
there be a number of bleeding points, time will be saved if a liga- 
ture be thrown about the omentum above these and the included 



PELVIC INFLAMMATION. 495 

portion amputated. This is of especial importance and advantage 
if it is thickened by inflammatory deposits. After having disposed 
of the omentum, the intestines must next be dealt with. If they 
are unadherent, the finger passes down through them into the 
pelvis, locating first the uterus, and then the Fallopian tubes and 
ovaries. Should the intestines be found adherent, they must first 
carefully but completely be freed from all points of attachment. 
The adhesions may exist at but a few points, and easily be broken ; 
on the other hand, they may be most extensive, and so solid that 
separation can only be accomplished with great difficulty and dan- 
ger of rupturing the bowel-walls. Every loop of intestine which 
overhangs the pelvis, even the vermiform appendix, has been found 
to be involved in the general mass. The separation of these, espe- 
cially if deep in the pelvis, is much facilitated by using the sight 
in addition to the touch. One of the great advantages of this is 
that the operator can be absolutely sure of what he is dealing with, 
and can see any commencing tear in the bowel-wall in time often to 
avoid a serious injury. The elevated hip — Trendelenberg — position 
allows the use of both touch and sight, and any surgeon who would 
willfully neglect the advantage to be derived from the combined use 
of these two senses does not do his whole duty to his patient. It is 
in this point of separating adherent intestines deep in the pelvis that 
the position gives its greatest advantage and becomes invaluable. 
The adhesions are freed by one finger being gently but firmly in- 
serted between the first knuckle of intestine which is adherent and 
the organ to which it is fast. A to-and-fro motion will often succeed 
in loosening it when a steady pressure at one point will accomplish 
nothing. If the adhesion is stubborn at one point, the finger glides 
to another and another, until it finds a weak point from which to 
begin : after the beginning is made the rest is comparatively easy. 
At times it will yield easily on top ; at others the first point of weak- 
ening will be found by passing the finger to the sides or even under 
the part. As each knuckle is freed it should be brought into the 
abdominal incision and carefully scrutinized. The points at which 
the adhesions existed will be found stripped of their peritoneum : if 
these points are small and not bleeding, they may be ignored ; if 
bleeding freely, a few superficial stitches of silk or catgut will bring 
the edges of the peritoneum together and stop all flow. Exposure 
to the air for a. short while may in itself stop it. If the serous and 
muscular coats are both torn through, stitches should be so placed 



496 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

as to turn the doubtful point into the bowel, and any possible danger 
of future perforation at these points will be obviated. When the 
intestines are all freed and properly treated, they, together with the 
omentum, are crowded back toward the diaphragm and a large 
sponge placed in the abdomen, so as to keep them out of the pelvis 
while the operation is completed : the sponge does the additional 
duty of absorbing any blood or septic material which may flow 
toward the abdominal cavity during the course of the subsequent 
manipulations. Should the bladder have become injured, it should 
be repaired before proceeding further. Each and every step of the 
operation is to be completed fully before proceeding to the next, so 
that no point in the technique may be forgotten in the final steps 
of the operation, or complications will arise to embarrass the subse- 
quent steps. It is well to locate and note the condition of both ap- 
pendages before beginning their enucleation, and usually it is best 
to free both of them and the uterus before beginning to place the 
ligatures. If this be done, the parts can be brought more fully and 
easily into the abdominal incision, and there will be less likelihood 
of the first ligature becoming loosened while adherent parts are 
being separated on the opposite side. In the enucleation the finger 
glides about over the parts until it finds a weak point or a point at 
which it can be passed down deeply into the pelvis. It is essential 
that this should be posterior to the broad ligament, between it and 
the sacrum. The Fallopian tubes and the ovaries are situated on 
the posterior surface of the broad ligament, and the adhesions will 
almost always be found at this point. The finger should glide 
between the appendage and the sacrum. It is well where possible 
to follow the curve of the sacrum, keeping the palmar surface of the 
finger — or fingers if two be used — toward the pubis, sweeping the 
finger from one side of the pelvis to the other and in this manner 
freeing all adhesions to this bone. This will allow the fingers to 
pass under the ovaries, tubes, and uterus if it be retrodisplaced, and 
they can be stripped loose and lifted out of the pelvis with com- 
parative ease. The aim should be to get the finger to the lowest 
point in the pelvis and work upward, and not from above downward. 
However, at times one is forced to work first at one point, and then 
abandon it and go to another and another, coming back finally to 
the original one. It is only by educating the fingers to the work 
that it can be performed accurately. In making the enucleation 
care should be taken to do as little damage as possible to the broad 



PELVIC INFLAMMATION. 497 

ligament, as it bleeds freely wherever injured. It may be necessary 
at times to ligate the one side before enucleating the opposite one, on 
account of the bleeding. If this should be the case, care must be 
taken not to loosen the ligature while completing the work. As 
soon as the appendages and uterus are freed the ligatures are to be 
placed and the diseased parts removed. The Fallopian tube and 
ovary are caught firmly in one hand and drawn well through the 
abdominal incision, while the other hand passes the pedicle staff 
containing the ligature through the broad ligament, it being well to 
pass it below the loop of the round ligament, which will readily be 
observed on the anterior aspect of the tense broad ligament. If 
this be done and care be taken not to cut the loop of the round 
ligament when the Fallopian tube and ovary are removed, there 
will be less danger of the ligature slipping from the stump. As 
soon as the ligature staff has perforated the broad ligament the 
staff is withdrawn and the silk left in situ as a double ligature ; 
the double end is then cut, and hangs as two separate threads 
perforating the broad ligament. The two strands of silk are so 
twisted that when their respective ends are tied, one around each 
half of the mass, they form a figure-of-eight, each half compressing 
one-half of the pedicle, and the two halves being drawn closely 
to each other. While placing the ligature the broad ligament should 
be held well up into the wound, but as the knots are tied tightly, 
the assistant who is holding the mass should relax his hold 
and allow the broad ligament to retract, else when the mass is 
cut away there will be a strong tendency on the part of the 
broad ligament to pull down through the ligature, thus causing 
hemorrhage. Care is to be taken that the Fallopian tube is 
included in the ligature up to the uterine cornua. In some cases 
it is necessary to include uterine tissue in order to get a pedicle 
healthy enough to hold the ligature without cutting through, and at 
times it cannot be done even then. Frequently the ligature cuts 
through the pedicle like a knife, completely amputating it. It be- 
comes necessary then to pass a ligature, by means of a curved 
needle, deep into uterine tissues at the cornua in order to control 
the bleeding. The same procedure may become necessary on the 
side of the pelvic wall. In such cases the proper treatment is the 
complete removal of the uterus, together with the appendages. Pa- 
tients with such lesions, when the appendages alone have been 
removed, are prone to return for treatment, suffering with leucor- 

32 



49S 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



rlieal discharge, pain, and continued bleeding : the uterus in such 
cases is often found to be still enlarged, and the writer has on several 
occasions been compelled to remove it in order to accomplish a cure. 
When the uterine apjjendages have been sacrificed the uterus is a 
useless organ : in case its retention should necessitate drainage on 
account of its mutilated and torn condition, in case its tissues be 
contaminated so as to threaten a subsequent or immediate infection, 




Ligation by Figure-of-eight Ligature of the Fallopian Tube and Ovary. 

in case it be so enlarged and diseased as to seem fairly probable that 
in future it will be the source of disagreeable or dangerous symp- 
toms to the patient, it may be removed by intra-peritoneal amputa- 
tion without hesitation. The ultimate results following the hyste- 
rectomy will be in a large number of cases superior to those follow- 
ing double ovariotomy alone. 

The Staffordshire knot, or the so-called Tait knot, is an exceed- 
ingly dangerous one, and should be avoided, especially by beginners. 
The knot is so complicated that it is difficult to tie, and should any 



PEL VIC INFLAMMA TION. 499 

one part of it be applied inaccurately and lightly, the whole loop is 
liable to become loose. Occasionally the pedicle is so large that it 
is not safe to include it all in one ligature. It is then best to tie in 
sections, quilting it from side to side as the cobbler does in his work. 
When the ligature has been firmly secured, the Fallopian tube and 
ovary are cut away, leaving sufficient of a button to ensure that the 
ligature will not slip off. After cutting away the appendage the 
stump should be seared with a Paquelin cautery as an antiseptic 
precaution. There is always a small portion of the lining mem- 
brane of the tube protruding from the centre of the stump often 
containing septic matter, which it is much safer to destroy than 
to leave free in the torn and denuded pelvis. When the ligatures 
are tightened, usually all free hemorrhage ceases and the only 
bleeding is merely an oozing, which will stop of its own accord in 
a short while. It may be advisable to place a ligature about some 
point which bleeds with especial freedom, but usually one or two 
of these at most are all that will be required. The points which 
will be most persistent and troublesome are those on the uterine 
surface. Wherever they are, if they are picked up with a pair of 
hemostatic forceps, and a ligature carried under them with a curved 
needle, they can readily be controlled. During the enucleation 
there should be no hemorrhage which is alarming, and generally it 
is better to ignore entirely what there is and finish freeing the adhe- 
sions with the certainty that the bleeding will end as soon as the 
ligatures are secured about the pedicles. Should the bleeding be- 
come alarming, it is because the ovarian artery has been severed, 
and it is best to secure the vessel by passing a ligature around 
it. If a needle be passed through the broad ligament near the 
pelvic wall and the ligature secured, and another one through 
the broad ligament near the uterus and secured, the vessel will be 
caught at both ends. The enucleation may then be finished and 
the mass tied away in the usual manner. There is neither necessity 
nor occasion for packing the pelvis with gauze or sponges to control 
hemorrhage during the course of the enucleation : such a procedure 
is not needed in the case of venous bleeding, and can only delay 
and impede the operation, while in arterial bleeding it will only 
control the hemorrhage as long as the pressure is kept up. The 
bleeding vessel must be ligated as soon as the gauze is withdrawn, 
and the result of its use is simply the loss of valuable time. 
If during the course of the enucleation the Fallopian tube or 



500 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

ovary, or both, be found distended with fluid, either purulent or 
otherwise, it may be well to empty them with the aspirator, so as to 
avoid their rupture during the operation, and consequent soiling of 
the torn and bleeding parts with septic matter. If possible, how- 
ever, it is better to remove the tumor without emptying it, as an 
enlarged ovary or Fallopian tube is easier to handle and enucleate 
than a small or collapsed one : care should be observed, however, 
not to rupture it. Should it rupture and the parts become bathed 
with the contents, or should one or more pus-pockets be found in 
the lymph surrounding the appendages and evacuated into the gen- 
eral pelvic cavity, the parts must be washed out thoroughly and all 
traces of the fluid removed. If the intestines and omentum have 
become soiled, they must also be washed carefully. For this pur- 
pose a long-nozzled irrigator is carried to the bottom of the pelvis, 
and several gallons of hot water are passed through it. To carry 
out this procedure two fingers of the one hand are placed in the 
upper angle of the abdominal incision to hold the intestines back 
toward the abdominal cavity ; the nozzle of the irrigator is then 
pressed toward the lower angle of the incision ; a funnel is thus 
formed through which the water from the bottom of the pelvis 
gushes freely, bringing with it all the pus, blood, and other debris 
which has been left there. The heat of the water acts in addition 
as a good hemostatic to the oozing points, and tends also to combat 
any threatened shock. While the irrigation is being carried out 
the fingers should play freely among the intestines, washing them 
thoroughly. The use of Trendelenberg's posture has in great measure 
done away with the necessity for irrigation. With this position the 
whole pelvis and all its contents are so thoroughly exposed to the eye 
that all debris can be 2-emoved with a sponge. Where irrigation is used 
the patient, for obvious reasons, should never be in the Trendelenberg 
posture. Before closing the abdominal wound a last look at the 
stump should be taken in order that any tendency to slipping or 
loosening of the ligatures may be noted and corrected. Should there 
be any doubt about their perfect safety, a ligature can readily be 
thrown around the ovarian artery on each side of the stump with 
the aid of a curved needle, thus rendering assurance doubly sure 
(see Fig. 279). It is seldom during the course of an operation of 
this kind that the ureters are injured : such accidents have hap- 
pened, however, and this possibility must always be borne in mind. 
(See Injuries to Ureter, chapter on Diseases of Bladder, Urethra, and 



PEL VIC INF LA MM A TION. 



501 



Ureters.) When large surfaces of peritoneum have been denuded and 
there is free oozing, when septic matter has soiled the seat of the ope- 
ration, or where a bowel has been badly damaged, drainage is at times 
indicated. Drainage is probably more often required in this class 
of operations than in any other in abdominal surgery. A drainage- 
tube of glass or gauze is passed to the most dependent point in the 
pelvis and brought out through the lower angle of the abdominal 
incision. The incision is closed, preferably; with a silkworm-gut 
suture, although the character of the suture is immaterial, pro- 
vided it is surgically clean. 

Frequently during the course of an operation the question arises 
whether or not certain parts should be removed. If it be necessary 
to remove the Fallopian tube on one side, its accompanying ovary 
had better go with it, and vice versa. Either Fallopian tube or 
ovary by itself is useless, and both are possible sources of future 

Fig. 279. 




Stump after removal of Uterine Appendages, showing iloulile ligation of Ovarian Artery. 

danger. Should the appendages on one side be healthy, it is unwise 
to remove them together with the diseased ones on the opposite side, 
for the reason that it renders the woman sterile and brings on the 
menopause with all its attending nervous phenomena. In spite of 



502 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

the fact that some good surgeons contend for the removal of both 
ovaries, it is better that the patient take the risk of a second opera- 
tion for the removal of the remaining one if in the future it become 
diseased. If the Fallopian tube is not already diseased, there is no 
good reason that it will become so if after recovery from the abdom- 
inal section the lining membrane of the uterus be treated and the 
endometritis cured. It becomes necessary, in any event, to adopt 
this course in many cases after the appendages have been removed, 
in order to secure a complete recovery. The disease originated in 
the uterus, and the fact that it has spread to the Fallopian tube and 
the pelvic peritoneum is no reason why it does not still exist intra- 
uterine. As a matter of fact, many of these patients are not cured 
until the womb has been curetted and treated by alterative and 
stimulating applications. 

The question often arises as to whether an operation should be 
performed in the presence of an acute peritonitis. If one have the 
choice, it were possibly best to operate in the quiescent state ; but 
if any indications for a speedy operation exist, no hesitation need 
be had on account of the inflammatory attack ; its cure will be 
assured on the removal of the appendages. The large masses of 
plastic lymph which accompany it are broken down and disappear 
in the course of the enucleation : within twenty-four hours the 
pulse and temperature, which were high at the time of the opera- 
tion, approach the normal, and the patient convalesces within forty- 
eight hours. Neither need menstruation be a bar to operation. 
When both appendages have been removed, there is always a. 
spurious menstrual flow within two days after the operation. The 
only possible disadvantage would be that the operation might be 
slightly more bloody on account of the pelvic congestion — not, how- 
ever, more than if an acute inflammatory attack were in progress. 

Vaginal Hysterectomy is preferred by some surgeons in the radi- 
cal treatment of pelvic inflammations. The operation is in every 
way inferior to abdominal section in that it, of necessity sacrifices the 
uterus, is a more difficult and prolonged manipulation, is more 
uncertain in the removal of all portions of diseased organs, is in- 
applicable to certain phases of the disease — for instance, compli- 
cating vermiform appendix inflammation — and in the fact that 
injuries to the hollow viscera, which occur far more frequently by 
the vaginal route, are incapable of being repaired short of an addi- 
tional abdominal section. 



PLATE XXVIII. 
Fig. 1. 




Fig. 1— Vaginal Hysterectomy with Clamps. Single-clamp operation. 

Fig. 2.— Vaginal Hysterectomy with Clamps. Multiple-clamp operation : first step. 



PEL VIC INFLAMMA TION. 



503 



Operators who make frequent use of the vagina as a route to the 
treatment of diseases of the pelvic organs adopt this method, not 
only for cases of pelvic inflammation, but for patients suffering from 
uterine and ovarian displacements, ovarian neoplasms of small or 
even moderate size, and small fibroid tumors, as well as various other 
pelvic ailments. 

Fig. 




Vaginal Hysterectomy : opening the posterior cul-de-sac, and suturing the peritoneum and the mucous 
membrane together to control bleeding. 



Whilst many gynecologists have fixed upon the vagina as the 
best channel through which the pelvic organs should be treated 
surgically, yet unanimity does not exist with regard to the technique 
of the operation. Some surgeons, at the head of whom stand Pean 
and Richelot, secure the broad ligaments, either in section by sev- 
eral catch forceps or as a whole by a single clamp on either side. 
Many, perhaps the majority of American surgeons, have adopted 
the multiple clamp procedure. This is usually a more rapid mode 
of operating than by the ligature, and the clamps are kept on only 
from thirty-six to forty-eight hours. 

It having been determined that there exists disease of the uterus 
and adnexa of a degree sufficient to warrant their removal through 
the vagina, the operator proceeds in the following manner: 



504 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

The patient is placed in the lithotomy position. The uterus is 
curetted and irrigated, but not packed with gauze. The cervix is 
grasped by a very heavy pair of traction forceps. A firm hold upon 
the cervix is essential. The posterior cul-de-sac is opened in the 
same manner as already described and illustrated in the article on 
posterior vaginal section (see Figs. 268-273). The operator then 
makes a thorough digital examination of the pelvic contents. 
If the adnexa are found adherent, they are loosened before 
any attempt at extirpation is made. At times it will be found 
impossible, owing to their high attachment, to reach the adhe- 
rent adnexa. When the operator has loosened all adherent struc- 
tures by means of his finger he proceeds to separate the uterus from 



the bladder. With a pair of stout scissors a semicircular incision 
is made through the mucous membrane at the cervico-vaginal junc- 
tion, the operator cutting toward the cervix. This incision on each 
side stops short of the median line. Still making firm downward 
traction upon the uterus, the operator pushes up the bladder away 
from the uterine tissue, being careful to keep his finger points and 
nails pressed hard against the uterus in order to avoid tearing the 
bladder. If it be possible to do so, the bladder should be separated 
entirely from its anterior attachments to the uterus and the perito- 
neal cavity entered in front. When the operator has succeeded in 
doing this, the middle finger of each hand is introduced between the 
bladder and uterus, while the index fingers are inserted into the 
cul-de-sac. Upon separating the hands to each side, the loose tis- 
sues on each side of the uterus are shoved away, such as the bladder 
and ureters. This is done to the extent only of freeing the uterus 
at the sides. The uterus will now hang by its broad ligaments 
round ligaments, and a narrow strip of vaginal mucous membrane 
upon each side. The arterial supply has not been interfered with 
or disturbed. Introducing the middle and index fingers of the left 
hand so as to grasp between them the broad ligament of the left side, 



PELVIC INFLAMMATION. 



505 



the operator shoves the tissues at the left of the uterus outward, and 
seizes with the hysterectomy forceps the uterine artery between the 
uterus and his fingers. The same thing is done on the other side. 
These two forceps will secure the uterine arteries. With scissors 
the tissues between each forceps and the cervix are severed almost 
to the point of the forceps. 

So far, the operation has been comparatively easy. The next 




The cul-de-sac has been opened and the bladder dissected from the uterus. The uterine arteries are 
grasped by forceps and the cervix has been dissected from the lateral stumps. (Photograph of opera- 
tion.) 

step is to secure the ovarian arteries outside the diseased adnexa. 
All retractors are removed. If the operator can antevert the uterus, 
he does so. As the corpus uteri appears beneath the bladder, the 
latter is lifted up with the fingers or a short speculum and a firm 
grasp is taken in the anterior uterine wall with traction forceps. 
As the corpus uteri comes still farther into view, another pair of 
traction forceps grasp it above the first pair and pull it still farther 
forward. The operator removes the first pair of traction forceps 



506 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



and catches the body of the uterus above the second pair. In this 
way, step by step, the corpus uteri is made to emerge beneath the 
bladder, so that the fundus and tubes may be seen. In accomplish- 
ing this, all down-traction upon the cervix must be avoided. In 
fact, the body of the uterus will rotate forward more readily if 
the cervix be pushed up with the fingers. When the operator 
has the tubes in view, the adnexa upon the woman's left are pulled 
beneath the bladder through the vesico-uterine incision until they 




The cervix has been shoved up so as to permit the operator to drag the fundus out beneath the bladder. 
Both cornua uteri are shown with the attached tubes. (Photograph of operation.) 

lie in front of the uterus. Standing up, the operator grasps the 
broad ligament outside the ovary with the thumb and index finger 
of the left hand, the index finger being posterior to the ligament, 
and applies the hysterectomy forceps from above downward, so as 
to grasp all the broad ligament between its upper edge down to the 
tip of the forceps on the uterine artery. The uterus is then cut 
loose upon this side. After freeing the uterus upon one side, the 
adnexa of the other side are pulled in front of the uterus, the 
fingers grasp the broad ligament, and the broad ligament is clamped 
from above downward. The uterus and adnexa are now cut away. 
If it appears more convenient to retro vert the uterus, this can be 




Fig. 3.— Vaginal Hysterectomy with Clamps. Multiple-clamp operation : second 
step 

Fig. 4.— Vaginal Hysterectomy with Clamps. Multiple-clamp operation: third 
and final step. 



PELVIC INFLAMMATION. 



507 



done by starting the process with a heavy male sound introduced 
into the uterus, and then progressively grasping higher and higher 
upon the posterior uterine wall with blunt traction forceps. Hav- 



Fig. 284. 




After delivering the fundus, the entire uterine body is pulled to the right in order that the left adnexa 
may be seized. The operator's thumb rests on the ovary, while his two first ringers grasp the corpus 
uteri. The forceps are being applied to the right ovarian artery. Notice the absence of retractors. 
(Photograph of operation.) 

ing brought the fundus uteri out through the posterior cul-de-sac, 
the adnexa are pulled into the vagina and the ovarian vessels 
clamped. 



508 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



Introducing two fingers of the left hand behind the uterus, the 
operator grasps the adnexa on the woman's left and pulls them down 
to a position posterior to the uterus, and places a pair of hysterec- 



Fig. 285. 




Having clasped the right ovarian artery, the uterus is cut away upon that side. The operator rotates the 
uterus, so that (lie cervix is delivered and the posterior surface of the uterus presents. He grasps 
the left broad ligament between his index and middle lingers, and applies the forceps to the left ova- 
rian artery. The method of applying these forceps is shown. (Photograph of operation.) 

tomy forceps on the broad ligament from above downward in such 
a way that the tip of one blade of the forceps is felt by the palmar 
surfaces of the fingers which are holding the uterus and adnexa. 
Applying the forceps in this way, he avoids grasping a 



PELVIC INFLAMMATION. 509 

prolapsed knuckle of intestine. This pair of forceps will secure the 
ovarian artery on the left side. The uterus is now freed upon the 
left side by cutting between the forceps and uterus with scissors. 
It is often necessary to use several pairs of clamps on each side of 
the uterus in order to secure the ovarian arteries. Every step of 
this work should be seen, even to the application of the forceps, so 
that the intestines may not be wounded. Having released the ute- 
rus entirely on one side, the operator grasps the adnexa upon the 
right with his left hand and pulls them downward and to the left, so 
that the adnexa and uterus lie in the hollow of the hand, the right 
broad ligament being grasped between the thumb and index finger. 
Standing up, the operator introduces the forceps from above down- 
ward outside the fingers which are holding the tissues, so as to grasp 
all that part of the broad ligament between the tips of the forceps 
on the uterine artery and the top of the broad ligament. The ute- 
rus is then cut away and removed. 

It is while working to secure the ovarian arteries that the ope- 
rator fully appreciates the advantages of having freed the uterus and 
adnexa from all adhesions before he applies any forceps upon the 
vessels. If he has failed to do this or cannot do it, he will find the 
operation most difficult. The one great essential to a smooth vaginal 
hysterectomy is to free the uterus and adnexa before hemostasis is 
begun. 

The specula are next introduced. Holding the bladder up and de- 
pressing the perineum and posterior vaginal wall, the operator intro- 
duces a gauze pad into the pelvis and pushes the intestines away from 
the stumps secured by his forceps, so that he may make a careful in- 
spection of the stumps and see if any bleeding is going on. If the 
adnexa have been thoroughly freed before extirpation is attempted, 
it will be seen upon completion of the operation that the bite of each 
pair of forceps is in the upper part of the vagina. No forceps, if 
possible, should ever be applied so as to project up into the pelvic 
cavity among the intestines. The gauze pad supporting the intes- 
tines is now removed, and a piece of iodoform gauze is inserted 
between the forceps and the wall of the vagina on each side to pre- 
vent pressure-slough. The operator now takes squares of iodoform 
gauze, each about two inches wide and three inches long, and intro- 
duces one piece along the side of the forceps on the left, a little above 
their tips. This piece of gauze is supported by a smooth, narrow 
speculum introduced to the right of it, the dressing forceps removed, 



510 AN AMERICAN TEXT- BO OK OF GYNECOLOGY. 

another piece of gauze introduced alongside the speculum, the specu- 
lum withdrawn, and this piece of gauze also supported ; and in this 
way the operator proceeds from one side to the other, filling the 
opening in the vagina entirely with iodoform gauze, which projects 
a little above the points of the forceps. A few more pieces of gauze 
are introduced lower down in the vagina, so as to fill it to the vulvar 
orifice. Sterilized gauze is wrapped around all the forceps and tied. 
A self-retaining catheter is introduced into the bladder and pinned 
to a piece of plaster fastened to the skin above the pubes. The 
sphincter ani is dilated and the patient put to bed. 

Sometimes, when the adnexa of one side are so firmly attached to 
the intestines, or are so large, or the vulva so small, that the ope- 
rator cannot loosen both adnexa to his satisfaction, he may proceed 
as follows : If the difficulty be limited to one side only — for example, 
the right side — he may free the adnexa on the left side, secure the 
uterine arteries on both sides, and the ovarian artery on the left side 
outside the ovary and tube ; he then cuts the uterus free on the left 
side. Having done this, he introduces a pair of forceps close to the 
uterus upon the right side where the adnexa have not been freed, 
and removes the uterus and adnexa of the left side, leaving in the 
tissues which embarrassed him. It will now be found that he will 
have room for removing under the guidance of the eye the remain- 
ing adnexa. In doing this the operator will secure the ovarian 
artery outside the ovary and tube, and this will render the pair of 
forceps which were applied between the uterus and right adnexa 
unnecessary, so they are removed. 

If the tissues are very soft, so that down-traction cannot be made 
without the forceps tearing through, or if the adnexa of both sides 
be so firmly attached, or other difficulties exist which render it im- 
possible for the operator to free the adnexa on either side, he pro- 
ceeds as follows : Having entered the cul-de-sac and after separating 
the uterus entirely from the bladder, he secures the uterine artery 
on each side with forceps, and with blunt scissors splits the uterus 
in the middle line up its anterior face ; as he cuts each fraction of 
an inch, it will be noticed that the cut surfaces turn out, and these 
he grasps on each side with blunt traction forceps and pulls down. 
Alternately cutting through the centre and going higher and higher 
up with his traction, the operator will arrive at the fundus uteri ; he 
then splits the posterior surface of the uterus with scissors. Very 
little bleeding is produced, and only parenchymatous in volume. 



PEL VIC IN FLA MM A TION. 



511 



Shoving the right half of the uterus and the right adnexa into the 
pelvis to one side, the operator proceeds with the enucleation of the 
adnexa on the woman's left, and, when he has them freed, nothing 
remains for him to do but to secure the ovarian artery on that side 
by applying forceps from above downward. The same thing is 



Fig. 286. 







Ovarian cyst, cystic ovary, and uterus removed perv 



by hemisection. Old nullipara. 



done on the other side. In other words, the operator, meeting with 
difficulties that he cannot overcome altogether, divides the difficul- 
ties by splitting the uterus. 

When the uterus is very large, the operator may proceed as fol- 
lows : Having opened both the posterior and anterior cul-de-sacs, 
he secures the uterine arteries with forceps. The cervix is now cut 
loose upon each side almost to the points of the forceps. It is now 
split bilaterally up to the point of the forceps. Grasping each flap 
with traction forceps, the operator amputates the anterior lip and 
seizes the stump, and the same is done with the posterior half. Or 
he may leave the posterior lip for traction purposes when the uterus 
is soft. He now splits the anterior wall of the uterus as high up as 
he can, and from each side, as he ascends, he cuts small triangular 
pieces of tissue, being careful not to wound the uterine-ovarian 
anastomosis on each side. If small fibroid nodules are met with in 
the uterus, they are dug out. Ascending the anterior uterine wall 
in this way, and removing cautiously all tissues to the lateral angles, 
the operator takes away piecemeal nearly all of the anterior half 
of the uterus. He has already secured the uterine arteries, and if 
he can grasp the ovarian now, he should do so and remove the rest 
of the uterine tissue, the adnexa being attended to later. The object 
of the morcellation is to enable the operator to reach the ovarian 



512 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



arteries, and this he cannot do until he has removed all uterine tis- 
sue which blocks his way. In some cases quite large fibroid tumors 
are removed by the vagina, 

Certain details connected with this operation may be elaborated. 
In the first place, special instruments are necessary, and chiefest of 
these are the hemostatic forceps. The bite should not be long — not 
over one and a quarter inches — and the points of the forceps should 
come together when the first catch is closed. The point of the for- 
ceps should always meet before the rest of the bite closes. This is 
very essential, otherwise the operator will find that when he crowds 
the forceps into the tissues and closes them an imperfect grasp is 
secured by the upper portion of the forceps, while the points do not 




Instruments used in cul-de-sac exploration and vaginal hysterectomy. 

constrict the tissues at all. This accident may cause the death of a 
patient from hemorrhage. No case should be put to bed after ope- 
ration until the operator has seen the ends of every tissue he has 
severed and assured himself that there is no arterial bleeding. 

Jf there be found a fistulous tract between a pus-tube or ovary 
and the rectum, sigmoid flexure, or small intestine, and this be so 
small that it can be sutured, stitches are to be taken in it. If the 
fistula be too large for suturing from the vagina, the operator should, 
after completing his vaginal operation and dressing the vagina, open 
the abdomen and repair the wounded bowel or vermiform appendix 
if that be seriously injured. Injuries to the bladder should be 
repaired at once. 

If it is thought desirable before placing the packings, the forceps 




Fig. 1.— Vaginal Hysterectomy with the Ligature : first step. 
Fig. 2.— Vaginal Hysterectomy with the Ligature : second step. 



PELVIC INFLAMMATION. 513 

may be removed and replaced by ligatures, either silk or catgut. In 
this case the stumps are drawn well into the vagina and the dress- 
ings introduced as already described. Or if the pelvis be a non- 
infected one, the vaginal vault may be closed by sutures (Plate 
XXI. Fig. 4), which, passing through the stumps, hold them fast in 
the vagina and prevent their retraction into the peritoneal cavity. 
This is the better method of finishing the vaginal operation. 

The dangers of vaginal hysterectomy, however performed, are 
sepsis, hemorrhage, vesico- vaginal or recto- vaginal fistula, and injury 
to the ureters. 

Where both appendages have been removed, the menopause 
usually becomes established. There are, however, frequent ex- 
ceptions to this rule, and patients return to the surgeon com- 
plaining that they are bleeding at regular intervals, and just as 
profusely as before. The cause for this has not been satisfactorily 
explained as yet. The explanation has been advanced that a small 
ganglion of nerves existed at the angle formed by the junction of 
the Fallopian tube and the uterus, and that there had been a failure 
to include and remove this ganglion with the appendage. Practical 
experience has long since proved the falsity of this theory. It has 
again been contended that an ovary — a third one — was left behind, 
but this has also been proved to be untrue : these cases of continued 
bleeding are quite frequent, while but few men have ever seen the 
mythical third ovary, in spite of the fact that an eminent German 
authority states in his book that it is possessed by about every tenth 
or twelfth woman. Some few of these patients are relieved of the 
flow by a thorough curetting of the endometrium : in others this pro- 
cedure has no effect. Usually, after a shorter or longer interval, men- 
struation, which at first remained fairly regular, becomes scanty, and 
finally disappears, the cause for its continuance remaining a mystery. 

The relief following the removal of the uterine appendages is 
not always the same, nor is the best result obtained immediately. 
If it is only necessary to remove one side, the menstrual function 
continues much the same as usual, and many of the benefits of the 
operation are realized at once. Of course the aches and pains, 
which occur more from habit than from any real lesion, continue to 
a certain extent until the patient returns to a good condition of gen- 
eral health. This requires time and building up. Should both 
sides have been removed, all the nerve-symptoms of the meno- 
pause appear within a few weeks after the operation, and the 



514 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

woman oftentimes feels worse than before the operation was per- 
formed. The menopause, which is artificial under these circum- 
stances, usually assumes a longer and more stormy course than 
when the woman changes naturally. The best effects of the opera- 
tion cannot be expected until this time is past, which may not be for 
•a year or two. The immediate relief from pain, however, is marked, 
and, although the woman is not altogether well, she is relatively 
and comparatively so : where she was a chronic invalid before, 
she is now able to be about and attend to her daily duties. The 
great trouble with surgeons is that they expect too much from the 
operation, and lead their patients to do the same. This is a great 
mistake. So much local damage has been done by the inflamma- 
tion, and the general health is so wrecked, that the woman will 
never again be the same well woman she once was : such a result 
is neither to be expected nor obtained in very many instances. 
An absolute cure should never be promised ; only relative results 
can safely be counted upon. 

The pain which so often remains with the patient after the ope- 
ration cannot always be accounted for. At times the omentum 
or intestine may become adherent to some denuded spot or to the 
stump. The dragging, incident to the peristaltic action would then 
give rise to pain. Frequently it is due to intestinal colic or to the 
compression of the nerve-filaments by the ligature. In some cases 
it is impossible to account for the pain on any other ground than 
that it was not originally caused by the ovarian or tubal disease, but 
resulted essentially from a nerve-disease from the first. An opera- 
tion for the removal of the uterine appendages for pain as the only 
indication is rarely justifiable. Whether or not there has been a 
pelvic inflammation, the surgeon should always be able to demon- 
strate positive disease of the Fallopian tubes and ovaries by a 
bimanual examination before counselling a surgical operation for 
their removal. The pain may be the result of a pelvic inflam- 
mation, but it does not follow that the removal of the appendages 
will cure this symptom, unless the appendages are diseased and can 
be shown to be the seat of the suffering. 

Some of the worst and most hopeless cases of pelvic inflamma- 
tion recover after an operation. This is particularly so in pus cases. 
It is surprising to note how quickly they rally even when they have 
appeared to be most desperate. For this reason no woman should be 
refused the chance of recovery because she may seem too far gone 



PLATE XXXI. 
Fig. 3. 




Vaginal Hysterectomy with the Ligature: third step. Fundus dragged into ye 
prior to placing final ligature. 



Fig. 4. 




Vaginal Hysterectomy with the Ligature : stumps drawn into the vagina, with 
sutures in place ready to close the opening in the vaginal vault. 



PELVIC INFLAMMATION. 515 

for relief: unless she is actually dying there is hope, and a con- 
scientious surgeon should offer her the last chance, forlorn as it may 
seem. The operation often means little more than the opening of 
an abscess, but, whatever it amounts to, a short etherization and a 
short operation frequently makes the difference between life and 
death with a patient : what is done should be performed as quickly 
as is compatible with safety, and the patient gotten back into bed. 
Should the enucleation give promise of being a long or hard one, 
and the patient apparently unable to stand it, it were better to 
empty out the pus and place a drainage-tube, leaving the com- 
pletion of the operation to some future time when the woman is 
better able to sustain the shock of the necessary manipulations. 

From time to time different substitutes have been sought for the 
removal of the appendages in pelvic inflammation. It has been 
proposed to open the abdomen, break up all the adhesions, and 
allow the parts to remain in situ. Again, it has been stated that 
it was proper to free the adhesions of a Fallopian tube containing 
pus, and squeeze the pus into the uterus by stripping the tube with 
the fingers. The fimbriated end of the tube being cut away and 
its cavity washed out, the cut end is stitched into the abdominal 
opening or the mucous and serous membranes brought together over 
the denuded portion. All manner of such procedures have been 
practised in the name of conservatism, each and every one of them 
being, in fact, more tedious and more dangerous than the complete 
removal of the diseased and destroyed appendages. The only justi- 
fication of such surgery would be subsequent pregnancy. As yet 
there is little reported which is encouraging from that standpoint. 
To open the end of the Fallopian tube, which Nature has sealed to 
prevent the further escape of infectious matter, is only to invite 
the infection of the whole pelvic if not abdominal cavity. Fortu- 
nately, Nature again seals the opening with plastic lymph within a 
few hours after it has been returned to the abdomen, and the whole 
procedure has been nullified so far as the results expected are con- 
cerned. Such surgery is useless in this class of diseases, and can 
only end in disappointed hopes. The moment the parts are returned 
to their position in the pelvis they re-adhere. 

Is there, then, no hope of a cure for these women short of the 
removal of the appendages? If they are able to bear their suffer- 
ings until the change of life is established, Nature will effect a cure. 
Pelvic inflammatory disease is essentially an affection of youth and 



516 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

middle age ; it seldom occurs in virgins or after the change of life. 
After the menopause it gradually becomes inactive, and finally ceases 
to give rise to any symptoms. As to whether or not a patient be 
advised to wait for this natural cure will depend much upon her 
suffering, the length of time she has to wait, the condition of her 
general health, and her station in life. A well-to-do woman could 
readily tide over a few years more or less with comparative comfort 
and safety, while her less fortunate poor sister would be forced to 
call upon the surgeon for relief. 

The changes which take place in a woman following the removal 
of both uterine appendages are the same as follows the natural change 
of life — none other, none less. The woman is sterile ; she was usu- 
ally sterile at the time of the operation, and would never have been 
anything else. Often the sexual appetite is increased ; rarely 
diminished, as is commonly supposed. The increase is simply 
the return of the woman's natural condition. Her pain and suf- 
fering and ill-health had inhibited the sexual appetite ; these being 
removed, the appetite returns in full force. Gradually over the 
course of years the apj)etite fades in exactly the same manner as it 
does following the natural menopause. In some women it is lost in 
a few years, in others not for many. The woman takes on a growth 
of flesh and becomes more matronly ; otherwise there is no change 
— no coarseness, no growth of hair on the face, no harshness of the 
voice, no masculine appearance. 

As a result of neglected pelvic suppuration, pus frequently 
finds its way to the surface and discharges ; oftener the patient dies 
of exhaustion and septicemia before this result is attained. Fistu- 
lous openings may appear in the rectum, the small intestines, the 
vagina, the bladder, the perineum, the abdominal walls, and the 
gluteal region. If the abscess has been unattended with involve- 
ment of the uterine appendages, sinuses will probably close and all 
signs of suppuration cease. If, on the other hand, the appendages 
are involved in the suppurative process, as they most frequently are, 
the sinuses will remain open in spite of all that may be done by way 
of medical treatment; the discharges continue, and the patient grad- 
ually becomes more and more exhausted and emaciated, until she 
finally becomes bed-ridden, and dies after a long period of suffer- 
ing and misery. The treatment of such cases is unpromising. 
Abdominal section with removal of the abscess-sac is the only 
alternative, however bad the case may be. When the pelvis has 



PELVIC INFLAMMATION. 517 

been cleansed of the diseased appendages which form the focus of 
suppuration, there is of course a sinus opening into the pelvic cavity. 
This is a source of great and threatening danger to the woman for 
the first twenty-four or forty-eight hours after operation, but it is a 
risk which she must necessarily assume : there is no avoiding it. 
The sinus should be well irrigated from within the pelvis outward 
in whatever direction it runs, and it should be disinfected as 
thoroughly as possible throughout its whole course. If it passes 
through any considerable amount of tissue, it is well to introduce a 
drainage-tube into its outer end, so as to ensure the flow of suppura- 
tive material away from the pelvic cavity. The mouth of the sinus 
in the pelvis is to be thoroughly scraped, cleansed and closed by 
a few catgut stitches. Nature will in a few hours add additional 
barriers to any infection entering the pelvis by sealing the opening 
with plastic lymph. Should the opening be into the bladder or 
bowel, the edges of the perforation are carefully to be prepared and 
closed with stitches. It is possible that the condition of the bowels 
will be so bad that in the case of the small intestine a portion must 
be resected. When the opening is too low down in the rectum for 
closure, a drainage-tube must always be placed at the point of open- 
ing, and the bowels kept perfectly quiet with opium for three or 
four days, so that no fecal matter may escape before the opening is 
sufficiently closed by lymph. 

It is possible in a goodly number of these extreme cases to get a 
good result, and when the patients do pass through the operation 
safely, it is surprising to see how quickly they regain their health 
up to a certain safe point. At times they are so badly wrecked that 
perfect recovery is a matter of years. The adhesions are so exten- 
sive and dense, the patient in such a low physical condition, and the 
damage to viscera so irreparable in many cases, that they are unable 
to stand the necessarily prolonged operation or they succumb to septic 
peritonitis. This, however, should be no reason for staying the sur- 
geon's hand so long as he can give a reasonable chance of cure to a 
respectable proportion of such cases. These cases invariably die if 
left alone, and each one cured is a life snatched from the grave. 

The sooner the general profession becomes thoroughly imbued 
with the vast importance of the whole subject of pelvic inflamma- 
tion, and acts intelligently upon the principles here laid down, the 
sooner will we have to face a lesser number of such terrible examples 
of neglect and ignorance. 



ECTOPIC GESTATION. 



Definition. — By the term " ectopic gestation " is meant a preg- 
nancy situated outside the cavity of the uterus, and the title ectopic 
is preferred to that of extra-uterine, as including, also, pregnancy 
in the interstitial portion of the tube, which, while ectopic, is not 
outside of the uterus. 

Cornual pregnancy will not be included in this article. 

History. — We shall not enter into the history of the subject, 
save to say that Albucasis, in the middle of the eleventh century, 
described the first known case of ectopic gestation. For centuries 
it was considered one of the rarest of Nature's freaks, but since 
March 3, 1883, when Lawson Tait of Birmingham, Eng., performed 
his first successful operation on a case of ruptured ectopic gestation, 
examples of this condition have been observed so frequently that 
the literature of reported cases is voluminous, and to Tait and his 
views of the etiology and treatment of pelvic hematocele are largely 
due our knowledge of the subject now before us. Instead of regard- 
ing the condition a rare one, we know now that it is comparatively 
frequent, and that every gynecologist in active operative practice 
must meet with several cases each year. Formad of Philadelphia, 
in a series of 3500 general autopsies, found 35 ectopic gestations. 

The relative frequency of this condition at the present time, as 
compared with the past, simply means that we are now better able 
to recognize such cases ; and many of the deaths formerly assigned 
to idiopathic peritonitis and to hematocele were undoubtedly due to 
ectopic gestation. 

Varieties. — For all practical purposes we may regard the tube 
as the primary seat of the ectopic gestation. When the fimbriated 
extremity of the tube is adherent to the surface of the ovary and 
embraces one or more Graafian follicles, we admit the possibility, 
after rupture of the follicle, of impregnation of the ovum before it 
leaves the follicle, and its development within the ovary, consti- 
tuting, in one sense, an ovarian pregnancy. Such an event, how- 
ever, if it ever occurs, would be so extremely rare that it may be 
left out of consideration in a practical work like this and ectopic 
gestation be regarded as originally tubal. 

518 



PLATE XXXII. 




Combined Ectopic and Intra-uterine Gestation; operation five months after marriage: A, tube 
and ovary removed at operation ; 1, gestation-sac containing amnion and giving chorionic villi under 
the microscope; 2, fimbriated extremity; 3, ovary; B, fetus contained within its membranes, passed 
from the uterus on the day following the operation. 



ECTOPIC GESTATION. 519 

The idea that an " abdominal pregnancy " ever occurs primarily, 
as such, has been abandoned. It seems neither rational nor possible, 
when we consider the absorptive power of the peritoneum, that an 
ovum should drop into the peritoneal cavity, meet with a spermato- 
zoon, and develop there. Knowing as we do how easily much 
larger and firmer masses are rapidly absorbed by the peritoneum, 
we do not believe that a young fertilized ovum would long escape 
destruction. We shall show later on how the condition called 
" abdominal pregnancy " originally started in the tube. 

Three varieties of tubal gestation are recognized, according to 
the situation : 

1. Tubal proper (free tubal) ; 

2. Tubo-ovarian ; 

3. Tubo-uterine or Interstitial. 

The first variety, that situated in the free portion of the tube, 
between the cornu of the uterus and the fimbriated extremity, 
includes by far the largest number of cases, and consequently is of 
the greatest importance. 

The tubo-ovarian variety we consider as still sub judice. As 
usually described, it includes the condition where the fimbriated 
extremity of the tube is adherent to the surface of the ovary, and 
the gestation takes place in the outer extremity of the tube, between 
it and the ovary. This variety is rare, and, as the treatment would 
be similar to that of the first variety, and the diagnosis would in all 
probability only be made at the operation or the autopsy, they will 
be considered together. We shall see later on that the direction of 
rupture may differ in the two cases. 

Careful observation of specimens of ectopic gestation removed 
by operation has largely modified the views held concerning the 
tubo-ovarian variety. In all probability cases have been reported 
as tubo-ovarian in which the ovary, just as coils of intestine or the 
uterus, simply formed a part of the sac created by adhesive perito- 
nitis binding together adjacent organs about the blood-effusion, re- 
sulting from rupture of any portion of the pregnant tube. 

In the tubo-uterine or interstitial variety the gestation occurs in 
that portion of the tube which is embraced by the uterine wall. 
This constitutes a distinct class, and will be considered separately. 

Etiology. — Concerning the etiology of ectopic gestation very 
little is known. The theory which has gained the widest accept- 
ance is, that it is due to some lesion in the interior of the tube 



520 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

obstructing the ovum in its passage to the uterus. This lesion is in 
some cases a desquamation of the epithelium, in a very few a sten- 
osis of the lumen by the traction of peritonitic adhesions causing an 
angulated condition of the tube, and in others a change in the epi- 
thelium short of desquamation (a destruction of the cilia), but suf- 
ficient to cause a departure from its normal function. The theory 
of lesion in the interior of the tube seems to cover a large number 
of cases, and is strengthened by the fact that frequently a history of 
previous trouble on that side of the pelvis can be elicited, and the 
event is often, though not always, preceded by a period of sterility. 

In some cases of ectopic gestation, on the other hand, the micro- 
scope has disclosed in the epithelium no deviation from the normal. 

Recent investigations have shown that in certain cases of preg- 
nancy decidual cells occur in the tubes as well as in the uterus. 
The view is therefore advanced that ectopic gestation is only possible 
in tubes containing decidual cells, and in such tubes anything delay- 
ing the progress of the ovum would favor the lodgement and ectopic 
development of that body. 

This disaster may occur at any age : it may happen in a woman 
who has borne several children, or it may occur in the first preg- 
nancy a few months after marriage. 

As stated above, the event is often preceded by a long period of 
sterility, and yet it may follow a confinement by only a few months ; 
in fact, it may accompany an intra-uterine pregancy. In this case 
the presence of the intra-uterine gestation may perhaps be the cause 
of the extra-uterine. 

Pathology. — We must consider — 

1. Changes which occur in the tube ; 

2. Changes which occur in the ovum. 

Following the lodgment of the ovum in the tube, the wall of the 
latter at first thickens ; this is chiefly due to its increase in vascu- 
larity, especially at the site of attachment. As the ovum grows the 
tubal wall becomes thinned and weakened by the ingrowths of the 
chorionic villi. Simultaneously with the growth of the ovum, the 
fimbriated extremity of the tube becomes progressively narrowed, 
until at about the eighth week it is completely occluded. The 
method of this occlusion has been accurately described by Bland 
Sutton. As the structures of the tube become swollen from the 
congestion, the peritoneal and muscular coats of the fimbriated ex- 
tremity form a prominent ring about the fimbriae ; this ring grad- 



ECTOPIC GESTA TION. 521 

ually projects beyond the firnbrise, then contracts and closes the 
ostium, leaving the fhnbrise within the tube concealed from view. 
Now, until this occlusion occurs, either one of two events is 
possible : 

1. Rupture of the tubal wall ; 

2. Tubal abortion. 

After the occlusion of the fimbriated extremity the ovum can 
escape from the tube only by rupture of its wall. As the chorion 




Gravid Fallopian Tube at the Tenth Week, showing complete occlusion of the ostium : o, ovary with 
corpus luteum. 

develops, the tubal wall, thinned by distension and weakened by the 
inroads of the villi, finally yields, the exciting cause coming either 
from without or from within the tube. 

(a) From without: As a misstep, lifting, straining, or, not 
infrequently, from sexual intercourse, as was proven to be the case 
in the patient from whom the accompanying specimem (Plate XXX.) 
was taken, where the rupture immediately followed that event. 

(b) From within : As a hemorrhage into the sac from separa- 
tion of the tubo-ehorionic vessels in the process of organic growth. 

This rupture, when the gestation is situated in the tube proper, 
may take place in either of two directions : 

1. Through a portion of the tube covered by peritoneum — viz. 
into the peritoneal cavity. (See Fig. 289.) 

2. Through a portion of the tube not covered by peritoneum — viz. 
between the folds of the broad ligament — i. e. outside the peritoneal 
cavity. (See Fig. 290.) 



522 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



In the tu bo-ovarian variety the direction of rupture would be 
into the peritoneal cavity only. 

When a rupture takes place into the peritoneal cavity, either 
one of two events may occur : 

(a) The hemorrhage may be sufficient to prove speedily fatal ; 

(b) The hemorrhage may be insufficient to prove speedily fatal. 
In the latter case the tubal laceration is small : the chorion in its 

Fig. 289. Fig. 290. 





Diagrammatic Section of Fallopian Tube, representing the two directions of rupture in tubal pregnancy: 
A, into the peritoneal cavity ; B, between the folds of the broad ligament ; 6, wall of Fallopian tube ; 
c, cavity of broad ligament. 



attempted escape plugs the opening and checks further hemorrhage ; 
the effused blood then gravitates to the pouch of Douglas, finally 
coagulates, and is roofed in by peritonize adhesions. In this way 
a new false sac is formed. As the chorion grows this new sac is 
ruptured, with a second hemorrhage, which in turn may be fatal, 
or may again be arrested and the fatal event postponed. This 
process may be repeated several times, or, indeed, if the effused 
blood is small in amount and the rupture occurs early, the effused 
blood, fetus, and membranes may be absorbed and the patient 
recover. 

The death of the fetus usually occurs with the first hemorrhage, 
but Webster reports and minutely describes a case in which the 
fetus escaped into the peritoneal cavity and went to term, the so- 
called placenta remaining in the tube. This may have occurred 
either by a marked distension and thinning of the tube, allowing 
the gradual escape of the fetus through the tubal wall, with little or 



d- o 




ECTOPIC GESTATION. 523 

no hemorrhage, or the fetus may have gradually escaped through 
the fimbriated extremity — i. e. by tubal abortion. 

When the rupture occurs through the floor of the tube, between 
the folds of the broad ligament, the death of the fetus also usually 
occurs at once. 

Occasionally, however, the chorion only gradually changes its 
site of implantation, and the fetal circulation is maintained ; fetal 
life continues, and may go to full term with complete develo}:>ment 
of the child. 

Thanks to the frozen-section studies of Dr. Berry Hart, we now 
understand pretty clearly the changes which occur as the fetus 
develops. These changes were well exemplified in the case, the 
specimen of which is illustrated by the accompanying plate taken 
from a photograph. The folds of the broad ligament are opened 
out; the peritoneum is gradually lifted from the floor of the pelvis, 
from the lower portion of the rectum, and from the side, posterior 
surface, and fundus of the uterus. The uterus itself is enlarged, 
and usually pushed to the side opposite the gestation-sac. 

The distance the peritoneum may be lifted from the pelvis and 
its contents without its rupture, by the gradual development of the 
fetus or by repeated hemorrhages beneath it, seems almost incred- 
ible to one who has not actually seen it either at operation or 
autopsy. This elevation not infrequently reaches to the level of 
the umbilicus or above, and explains how an incision may be made 
into the gestation-sac, to one side of the median line, without going 
into the peritoneal cavity. We say, " to one side of the median 
line," for although the peritoneum may be stripped from the side, 
posterior surface, and fundus of the uterus, it seems to remain 
attached to the anterior surface, especially at its lower portion, and 
an incision in the median line would usually go through the peri- 
toneum. 

The distension of the broad ligament and the elevation of 
the peritoneum is well shown in Fig. 291. 

The amount of distension which the peritoneum forming the 
folds of the broad ligament will tolerate is sometimes exceeded, and 
a secondary rupture occurs into the peritoneal cavity, the primary 
rupture having taken place extraperitoneally — viz. from the tube 
down between the folds of the broad ligament; the secondary 
rupture from the broad ligament into the peritoneal cavity. Either 
one of two results may follow this event : 



524 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



1. Profuse hemorrhage into the peritoneal cavity, with or with- 
out the escape of fetus or fetus and placenta ; 

2. The gradual escape of the fetus into the peritoneal cavity, 
with little or no hemorrhage, the placenta retaining its attachment 
within the broad ligament and the fetus perhaps continuing its 
existence. 

The first result, profuse hemorrhage, is more likely to occur 
when the distension of the broad ligament is due to recurring hem- 

Fig. 291. 




Transverse Section of the Pelvis of a Woman, with an Embryo and Placenta of the Fourth Month 
of Gestation occupying the Right Broad Ligament. 



orrhages, and will be referred to again as one of the possible indica- 
tions for operation in the treatment of an extraperitoneal rupture. 

The second result, escape of the fetus with continuance of its 
life, is of great interest anatomically, as it explains the majority of 
the cases in which a fetus has been found free among the intestines, 
and has given rise to the erroneous impression of primary abdom- 
inal pregnancy. 

We believe that by far the most usual place for the growth of an 
ectopic fetus escaped from the tube is between the folds of the broad 
ligament. Webster (Tubo-peritoneal Ectopic Gestation) has demon- 
strated the possibility of such a growth where the fetus gradually 
escaped from the tube directly into the peritoneal cavity and there 



ECTOPIC GESTATION. 



525 



developed. This, however, must be only a very rare exception to 
the rule that full-term ectopic fetuses are extra-peritoneal. 

Tubal Abortion. — By this term is meant an expulsion of the 
ovum from the fimbriated extremity of the tube at any time before 
its occlusion. As this occlusion usually takes place before eight 
weeks, tubal abortion is considered possible only during the first 
two months. This event is likely to occur only when the ovum is 
implanted in the outer third of the tube. Our knowledge of tubal 
abortion enables us to understand many cases of effusion of blood 
into the peritoneal cavity in which we find at operation or autopsy 
a tube empty, but with a collapsed appearance, as though it had 
been previously distended ; and the true nature of the case is often 
placed beyond doubt by finding among the blood-clots either a 




Tubo-uterine Pre^iumey. 



fetus, fetal membranes, or a firmly-clotted mass, in the interior 
of which microscopical examination discloses chorionic villi. 

Tubo-uterine or Interstitial Pregnancy. — This variety of ectopic 
gestation includes those cases in which the impregnated ovum is 
lodged and develops in that portion of the tube which is embraced 
by the uterine wall. 



526 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



In its life-history this condition differs from the other varieties 
of ectopic gestation in the following particulars : 
(a). Period of growth before rupture; 
(b). Direction of rupture. 

Situated as it is within the substance of the uterine wall, rupture 
of the sac would not be expected to occur at as early a period as in 
the varieties called tubal proper and tubo-ovarian, and this is borne 
out in the histories of reported cases. The wall of the gestation-sac, 
instead of rapidly thinning, as occurs when the ovum is lodged else- 
where in the tube, markedly thickens, resembling the uterine wall 
in normal pregnancy, and rupture frequently does not occur until 
the end of the fourth month. 

Direction of Rupture. — An interstitial pregnancy may rupture 
in either one of two directions : 1. Into the abdominal cavity. (See 
Fig. 293.) In this case the hemorrhage, without operative interfer- 
ence, is profuse and rapidly fatal on account of the thickness and 
vascularity of the wall. 

Fig. 293. 




Diagrammatic Representation of Interstitial Tubal Pregnancy at (he Time of Rupture. 



2. Into the cavity of the uterus. Such an event is considered 
possible, but, as it would be almost impossible to positively diag- 
nose the condition from normal intra-uterine pregnancy, this direc- 
tion of rupture we must regard as still sub judice. 

Cases of interstitial pregnancy are, as a rule, only diagnosed 
during life at operation necessitated by an intra-peritoneal hemor- 



ECTOPIC GESTATION. 



527 
considered 



rhage, the pregnancy up to the time of rupture bein 
normal. 

Period of Tubal Rupture. — When the ectopic gestation is either 
of the tubal proper or tu bo-ovarian variety, the rupture usually occurs 
some time between the third and the twelfth week, more often near 
the eighth. In the interstitial variety rupture may occur at any 
time between the third and the twentieth week, more often in the 




Pregnant Fallopian Tube laid open, showing the fetus killed by hemorrhage into its membranes, but 
without the escape of the fetus from the tube. 

fourth month. In tubal abortion, as previously stated, the ovum 
may escape from the tube at any time prior to the occlusion of the 
fimbriated extremity which occurs at the eighth week. 

The isthmus of the tube, that straight narrow portion just out- 
side the uterus, seems little adapted to distension with the growth of 
the ovum, and in our experience rupture of the gestation-sac has 



528 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

occurred at an earlier period here than when situated in the ampulla 
of the tube. In a general way, then, we might say that an early 
escape from the tube is more likely to mean rupture of a sac situ- 
ated in the isthmus, or a tubal abortion, than a rupture of the 
ampulla. 

Changes in the Ovum. — Notwithstanding the implantation of 
the ovum upon foreign soil, the fetal portions of the placenta are 
developed much as they would be in the cavity of the uterus ; it is 
only the maternal portion which is lacking, but this causes insecure 
attachment of the chorion, and, as the fetus develops, a rupture of 
some of the tubo-chorionic vessels easily occurs. This usually causes 
the death of the fetus, with or without its escape from the tube. 

So long as fetal life continues the growth and development of the 
ovum seem fairly normal. When death of the fetus occurs early, 
however, with hemorrhage into its membranes, a condition is formed 
so resembling a uterine mole that it has been called " tubal mole " 
or " apoplectic ovum." 




Apoplectic Ovum, or Tubal Mole (natural size). 

The hemorrhage separates the ovum from the tubal wall, coagu- 
lates in the meshes of the chorion, causes contraction of the fetal 
sac by compression, and forms a mass resembling a dark-red blood- 
clot. This may be found in the tube, or, if the hemorrhage causes 
the death of the ovum at the same time it causes tubal rupture 
or abortion, the tubal mole may be found among a mass of blood- 
clots, either in the peritoneal cavity or between the folds of the 
broad ligament. This tubal mole may at first be mistaken for a 
simple blood-clot, but on section one can often find an amniotic 
cavity, as in Fig. 295, with or without a fetus ; or, if neither amnion 
nor fetus is discernible, a microscopic section will usually disclose 
chorionic villi. 



ECTOPIC GESTATION. 529 

As previously stated, the death of the fetus usually occurs at the 
time of its expulsion from the tube. Rarely, however, fetal life 
continues, and may even reach full term. After its expulsion from 
the tube the following changes may take place in the ovum or 
fetus : 

1. When the death of the ovum occurs early, forming a tubal 
mole, this may be absorbed by the tissues in which it is lodged, be 
it peritoneum or connective tissue. Rarely suppuration in it may 
occur, perhaps from the proximity of the rectum. 

2. When death of the fetus occurs after it has reached a con- 
siderable degree of development and its bony framework is well 
formed, it may for a long time remain quiescent, the liquor amnii 
being gradually absorbed. Subsequently it may mummify from 
absorption of the fluids of the fetal tissues ; it may calcify, forming 
a lithopedion, may be changed into adipocere, or the soft parts 
may suppurate and the fetal debris be discharged into the rec- 
tum, vagina, bladder, or through the abdominal wall. 

Symptoms. — The symptoms of a patient afflicted with ectopic 
gestation are of great importance, for by these symptoms, coupled 
with a careful study of the history of the £>atient, the diagnosis is 
usually made. 

In almost every case there has been some departure from the 
normal menstruation. Usually the patient has gone over her 
monthly period for a longer or shorter time, it may be only a few 
days or may be several weeks. Occasionally, however, no period has 
been skipped, but there has been some change in the character of 
the last menstruation ; usually a lessening in amount. Not infre- 
quently, instead of the menstruation coming on in the usual way, 
there is at first only a splash, just enough to stain the clothes, then 
an irregular dribbling, followed by a more or less irregular, con- 
tinuous brownish discharge containing debris. The early symp- 
toms of pregnancy are often present, such as morning nausea, sensi- 
tive breasts, etc. The patient often believes herself pregnant, and 
this is of assistance in diagnosis. 

The next symptom which may surprise the patient is a sudden 
attack of very severe, sharp pain on one side of the abdomen : this 
pain is usually excruciating, causing the patient to feel faint, grow 
pale, and perhaps lose consciousness ; she is often covered with cold 
perspiration ; she not infrequently vomits ; the pulse becomes rapid 
and the temperature subnormal. Usually about this time metror- 



530 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

rhagia appears, and may continue several weeks, being due to the 
separation of the uterine decidua. As shreds are usually passed 
from the uterus, the patient often believes she has had a miscarriage 
and that her troubles will soon be at an end. Following this attack 
of pain, symptoms of pelvic peritonitis often present themselves. 
They may subside and the patient be up and around, when she is 
suddenly seized with another attack of sharp pain, syncope, etc., 
perhaps even worse than the preceding. 

Careful inquiry into the history of these cases often elicits the 
fact that the patients have been sterile for a longer or shorter 
period ; to this, however, there are many exceptions. To recapit- 
ulate, we would call attention to the following symptoms : 

(a) Amenorrhea; 

(b) Symptoms of pregnancy ; 

(c) Sudden sharp pain with syncope ; 

(d) Metrorrhagia ; 

(e) Often a history of previous sterility. 

Physical Signs. — If examined prior to rupture, one simply 
feels a distended tube, perhaps a little more boggy and vascular 
than a hydro- or pyosalpinx of a corresponding size. There is the 
same elongated, sausage-shaped mass, extending from the cornu of 
the uterus laterally or downward and backward, which one feels 
in a salpingitis. The uterus is enlarged ; the cervix is soft and 
patulous. 

If seen at the time of, or soon after, a primary intra-peritoneal 
rupture, the physical signs are often very meagre. There is usually 
no distinct tumor, and one can only get the sensation of fluid blood 
or an indistinct doughy feel in the pelvis and the constitutional 
symptoms of internal hemorrhage. 

When the rupture has occurred between the folds of the broad 
ligament, one gets all the physical signs of a pelvic hematoma. 

Let us now digress a little and consider the conditions pelvic 
hematocele and pelvic hematoma. By pelvic hematocele we mean an 
effusion of blood into the peritoneal cavity. This would naturally 
gravitate into the pouch of Douglas should this not be obliterated, 
or, if profuse, the blood may rarely flow over into the utero-vesical 
pouch as well. Coagulation, although longer delayed than in blood 
effused into connective tissue, finally occurs, and the blood-mass is 
roofed in by peritonitic exudate binding together adjacent struc- 
tures — coils of intestine, omentum, and uterus. 



ECTOPIC GESTATION. 531 

Etiology. — Concerning the etiology of pelvic hematocele our 
ideas have changed greatly within the past few years. While for- 
merly the text-books contained long lists of causes of this condition, 
operative experience has taught us that in nearly all cases we can 
assign but one cause — viz. ectopic gestation ; and, as the source of 
the blood, the tube, either from rupture or from tubal abortion. To 
this general rule we admit exceptions. We know that after the 
enucleation of diseased tubes and ovaries, or tumors of the same, 
an oozing surface is left which often gives rise to quite a large 
effusion of blood ; here, however, the cause is plain, and would not 
produce confusion. We also admit the possibility, from a slight 
traumatism, of rupture of peritonitic adhesions, some of which are 
markedly vascular, and would cause a considerable blood-effusion. 
Other possible causes are rupture of an ovarian hematoma or exces- 
sive hemorrhage from the rupture of a Graafian follicle. These 
events, however, would only rarely occur, and may be considered as 
exceptions to the general rule stated above. Most of the cases of 
regurgitation of blood from the tube we believe to be instances of 
tubal abortion. 

Physical Signs. — Previous to the encapsulation of the blood- 
effusion the physical signs are very few. There is a fulness in the 
pouch of Douglas which gives to the finger the impression of thick 
fluid, and from the floating up of the intestines there is usually more 
or less distension of the abdomen. When the effusion becomes 
encapsulated by peritonitic adhesions, the mass becomes firmer to 
the touch, the posterior fornix bulges, and the uterus is pushed 
forward. As the blood coagulates, the increase in the density of 
the effusion becomes apparent to the examining finger. The course 
and prognosis of pelvic hematocele are usually similar to ectopic ges- 
tation with intra-peritoneal rupture, and will be discussed later. 

By pelvic hematoma we mean an effusion of blood into the con- 
nective tissue beneath the peritoneum — viz. between the folds of the 
broad ligament. Here, again, although other causes are probably 
more common than in a pelvic hematocele, a very common cause is 
the rupture of an ectopic gestation-sac. The reason for considering 
other causes more frequent than in hematocele lies in the fact that 
varix of the broad ligament, due to various causes of venous con- 
gestion, is common, and where such is present but a slight trau- 
matism is required to produce a blood-effusion. 

Physical Signs. — These differ from those of a pelvic hematocele. 



532 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

While in the latter there is at first no limiting membrane, in the 
former the effusion is clearly limited by the folds of peritoneum 
forming the broad ligament, and a distinct tumor is developed. 
This tumor bulges down on one side of, and behind, the cervix, 
pushes the uterus forward and to the opposite side, and can be felt 
above Poupart's ligament when it has lifted the peritoneum from the 
pelvis. It seems to occupy all the space between the uterus and 
the sides of the pelvis, and if the finger is inserted into the rectum, 
the effusion, especially if situated on the left side, is found to have 
surrounded it, thus producing a stricture. This is due to the ring 
formed by the attachment of the peritoneum to the second portion 
of the rectum. 

Concerning the changes in a pelvic hematoma, two are possible : 

1. Absorption. This is possible even when the tumor is of quite 
a considerable size ; 

2. Suppuration. This seems frequently due to the proximity of 
the rectum, or if the hematoma is due to a ruptured tube, infection- 
may come from the uterus through the stump of the lacerated tube. 
The suppurating hematoma may rupture into the rectum, vagina, 
bladder, or rarely above the pelvic brim. 

Diagnosis of Ectopic Gestation. — For a clearer discussion, 
this may be divided into two periods : 

1. Prior to tubal rupture or abortion ; 

2. Subsequent to tubal rupture or abortion. 

Few opportunities are presented for diagnosing ectopic gestation 
during the ante-rupture period. Unfortunately for the diagnosis, 
the patients during this period are apt to suffer but little. A large 
proportion of the cases have absolutely no symptoms leading them 
to suspect an abnormal condition. Occasionally, however, perhaps 
from surprise at the symptoms of pregnancy after a long period of 
sterility, or in their first pregnancy, in order to determine if that 
condition really exists, or from pain in one inguinal region, they 
present themselves to the physician, and under these circumstances 
the diagnosis has been made a number of times and its correctness 
verified by subsequent operation. 

To enable one to make a diagnosis of ectopic gestation prior to 
rupture we would emphasize two rules, which we consider of great 
importance : 

1. Whenever a pregnant woman presents herself with a mass at, 



ECTOPIC GESTATION. 



533 



the side of or behind the uterus, always think of the possibility of 
ectopic gestation. 

2. Whenever any irregular symptoms of pregnancy occur the 
menstrual history should always carefully be inquired into, noting 
any change in its character, the exact duration in days, and its rela- 
tive amount during each of the months which are open to suspicion. 

The reason that so many more diagnoses of ectopic gestation are 
now made than formerly, and made correctly, lies in the fact that 
we are now on the watch for that condition. We need frequently to 
ask ourselves : Can this be ectopic gestation ? This is especially 

Fig. 296. 




Decidua expelled from the Uterus in a case of Ectopic Hestation : .4, rotated, so as to show the shaggy 
uterine side ; B shows the free surface. 

imperative when we meet with the early symptoms of pregnancy — 
nausea, sensitive breasts, softened cervix, etc., with a distended tube 
at the side of the uterus. This may be a hydro- or pyosalpinx 
simply coexisting with pregnancy. On the other hand, however, 
its boggy feel, a rather marked vascularity, and a careful observance 
of the second rule stated above concerning menstrual history may 
lead us to make a probable, if not a positive, diagnosis of ectopic 
gestation. 



534 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

Another factor in the diagnosis of this condition is the expulsion 
of the uterine decidua. While the ovum is developing in the tube 
there is forming in the uterus a decidua resembling that of a normal 
pregnancy, but differing from it in having a smooth, inner surface, 

Fig. 297. 




Decidua in Situ : fibroid uterus removed at time of operation for ruptured ectopic gestation. 

unbroken by the attachment of the ovum; in other words, having 
no decidua reflexa or serotina ; it is all decidua vera. This decidua, 
usually at or near the time of tubal rupture or abortion, is discharged 
from the uterus, sometimes entire, sometimes in small particles or 
shreds. It is a membrane varying from an eighth to a quarter of 
an inch in thickness, shaggy on the surface which is attached to the 
uterine wall, smooth, but presenting numerous fine wrinkles, on the 
inner free surface. On microscopical section it presents the appear- 
ance shown in the accompanying cut (Fig. 298). When passed en- 
tire it forms a triangular sac containing three openings, one corre- 
sponding to each Fallopian tube and one to the internal os. With 
the separation and discharge of this decidua there occurs a metror- 
rhagia which may continue for several weeks. The passage of these 
shreds with the subsequent metrorrhagia is often a source of error 
both to the patient and her physician, and a miscarriage is frequently 
the source of an erroneous diagnosis. 



ECTOPIC GESTATION. 



535 



There are two conditions from which the decidua from a case 
of ectopic gestation must be differentiated : 

1. The decidua of an intra-uterine pregnancy ; 

2. The membrane of a membranous dysmenorrhea. 

The decidua in an early miscarriage may resemble in places that 



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of an ectopic gestation, but in the former there is found evidence 
of implantation of the chorion, villi, etc. which is wanting in 
the latter. 

The condition called membranous dysmenorrhea is surrounded 
with much confusion. It is perfectly possible, in the light of recent 
experience, that some of the cases described as membranous dysmen- 
orrhea were in reality cases of ectopic gestation. The points on 
which we would lay the greatest stress in differentiating the dys- 



536 AN AMERICAN TEXT- BO OK OF GYNECOLOGY. 

menorrliea from the ectopic gestation would be the frequent recur- 
rent character of the former at the time of a menstrual period and 
the absence of the symptoms of pregnancy. According to Wyder 
and Ayers, the dysmenorrheal membrane does not contain the large 
cells seen in Fig. 298. 

The diagnosis of ectopic gestation has occasionally been made 
by curetting a uterus for supposed retained secundines, under the 
impression that the patient had had a miscarriage, and finding the 
uterus empty save for the decidua, which showed no chorionic villi. 

Diagnosis at the Time of, and Subsequent to, Tubal Rup- 
ture or Abortion. — This is usually not difficult if a careful 
history is obtained, and this is considered in conjunction with the 
present condition of the patient. If seen at the time of tubal rup- 
ture or abortion, we find, coupled with the history of the patient dur- 
ing the ante-rupture period, the symptoms of sudden shock and 
internal hemorrhage. The patient is suddenly seized with a sharp, 
excruciating pain, usually on one side of the abdomen. She feels 
faint, grows pale, perhaps loses consciousness ; the surface of the 
body is often covered with cold perspiration ; the pulse is rapid 
and feeble ; the temperature is often subnormal. These symptoms, 
especially if there has been a period of amenorrhea, should always 
suggest a ruptured ectopic gestation-sac. If the patient survives 
this primary rupture — and she frequently does — the symptoms 
abate, perhaps to be repeated at almost any instant, with or without 
a fatal result. 

If seen subsequent to the time of tubal rupture or abortion, we 
have, in addition to the history of early pregnancy, with one or 
more attacks of sharp pain and threatened collapse, the physical 
signs of either a pelvic hematocele or a pelvic hematoma, depend- 
ing on whether the rupture was intra- or extra-peritoneal. 

Differential Diagnosis. — The condition most likely to be con- 
fused with an ectopic gestation is probably a tube distended with 
either serum or pus, especially the latter. The physical signs 
of the two conditions prior to rupture often closely resemble each 
other, and, just as the rupture of an ectopic gestation-sac is fol- 
lowed by symptoms of shock and then peritonitis, so may the 
rupture or leakage of a pus-tube be followed by similar symptoms. 
The chief point in their differentiation is the difference in their 
clinical history. Here comes in the necessity for eliciting, if pres- 
ent, the symptoms of a possible early pregnancy. During the ante- 



ECTOPIC GESTATION. 537 

rupture period, as already stated, the greater vascularity and boggy 
feel of a pregnant tube may enable one to differentiate it from a 
pyosalpinx. 

Subsequent to the rupture the symptoms of the two conditions 
differ more widely : 

Ruptured Ectopic Gestation vs. Ruptured Pyosalpinx. 

Frequency of pulse greater. Frequency of pulse less. 
Temperature at first subnormal ; later rises Temperature rises steadily and markedly. 

slightly. 

Pain of shorter duration. Pain of longer duration. 

Patient shows loss of blood. Patient does not show loss of blood. 

Septic symptoms not usually present. Patient soon shows signs of sepsis. 

A fibro-myoma is sometimes confused with an ectopic gestation, 
and instances occur where the differential diagnosis is difficult. The 
means on which we rely are chiefly the difference in the history of 
the two cases : In the case of ectopic gestation the short history, 
first of amenorrhea, then attacks of sudden sharp pain, faintuess, 
and metrorrhagia ; in the case of the fibro-myoma a long history of 
gradual] y increased menstruation, and perhaps gradually increased 
pressure-symptoms, without the symptoms of early pregnancy. 

In physical signs the fibro-myoma is usually much more inti- 
mately connected with the uterus and harder than the ectopic ges- 
tation. Both conditions may coexist, as in the case from which the 
specimen (Fig. 297) was taken. 

Into the differentiation between pelvic hematocele and pelvic 
hematoma due to ectopic gestation and those due to other causes, 
we shall not enter, believing our present knowledge insufficient for 
the task, and that most cases of pelvic hematocele and hematoma, 
especially the former, are due to the rupture of an ectopic gestation- 
sac. We believe, however, that in the present state of our know- 
ledge we should not declare to be due to an ectopic gestation an 
effusion of blood in the pelvis found at operation or autopsy, unless 
we find either a fetus or chorionic villi, or unless we have obtained 
from the uterus a decidua devoid of chorionic villi. 

The appearance of the chorionic villi, as seen in section under 
the high powers of a microscope, is well shown in Fig. 299. The 
central portion of the villus is seen to be composed of irregular- 
shaped cells, while the outer wall consists of a single or double 
row of cubical epithelium. Sometimes several villi may be seen in 
a single field, but not infrequently a large number of sections have 
to be cut and examined before a single villus can be found. 



538 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



The differences in the physical signs of pelvic hematocele and 
pelvic hematoma have already been given, and we will here only 
refer to them. 

Tumors of the ovary are sometimes confused with ectopic gesta- 
tion, but a careful study of the menstrual history and a search for 

Fig. 299. 




Photomicrograph of Chorionic Villi, found in the tube of a case of ectopic gestation. 



the physical signs of pregnancy will usually enable one to arrive at 
a correct diagnosis. Mistakes, however, in diagnosing ectopic gesta- 
tion are bound to occur, even with the most careful, from the fact 
that the condition is sometimes found at operation, when not a 
period has been missed and not a symptom of pregnancy has 
been presented. 

Treatment. — In considering this division of our subject we 
would recognize two periods, requiring separate discussion : 



ECTOPIC GESTATION. 53& 

1. Prior to tubal rupture or abortion ; 

2. Subsequent to rupture : 

(a) Intraperitoneal. 

(b) Extraperitoneal. 

When the diagnosis of an ectopic gestation is made prior to the 
rupture of the tube, the question which must present itself to every 
conscientious gynecologist is : How can we best subserve the interests 
of our patient? The advocates of electricity claim that by the cur- 
rent, either galvanic or faradic, the fetus is killed and the products 
of conception are absorbed. Admitting this as a possibility, we 
still believe that we are not consulting the best interests of our 
patient by so doing. 

In spite of the unfortunate case of Matthews Duncan, referred 
to in nearly every work on this subject, in which high currents, 
both galvanic and faradic, were used without killing the fetus, we 
believe that in many cases, when seen early, electricity will kill the 
fetus, but that the danger to the patient disappears with the life of 
the fetus we cannot believe. Even after the death of the fetus, hem- 
orrhage into the tube sufficient to cause its rupture or tubal abor- 
tion, although it may not occur in every case, is still far from 
improbable. 

Further than this, while waiting for a cure by electricity or in 
the manipulation incident to its application, tubal rupture or abor- 
tion, with fatal hemorrhage, may occur before the surgeon has time 
to open the abdomen and remove the sac. A forcible illustration of 
this was the case illustrated by Fig. 300. The patient was moved 
from the bed to the table for the application of electricity. In so 
doing the tube ruptured, and before the surgeon could be obtained 
and the abdomen opened the patient was moribund from internal 
hemorrhage. 

Even if the fetus and membranes are absorbed under the use of 
electricity, a damaged tube is left, which is very likely to prove a 
source of future trouble. 

For these reasons we claim that electricity is not a satisfactory 
method of treating this condition. Galvano-puncture of the sac 
is dangerous, and ought never to be used. We believe that the 
method which gives the best promise of deliverance, not only 
from present danger, but from future trouble, is removal of the 
pregnant tube. 

We admit the possibility of a tubal rupture or abortion with only 



540 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



a slight hemorrhage, the absorption of the effusion, and the recovery 
of the patient. This is a possibility, but no one can tell when this 
is to be the result, or when a rupture is to occur with hemorrhage so 
profuse as to be fatal within a few hours without operative interfer- 



Fig. 300. 




Tubal Rupture in Case of Ectopic Gestation. 

ence. From the time an impregnation occurs in a Fallopian tube 
until the tube is removed, that patient is never free from danger. 

Moreover, during the period prior to the rupture of the tube 
the operation for the removal of the gestation-sac is one of the 
simplest in abdominal surgery, and in the hands of a skilled 
operator should have a mortality nearly nil. 

Let us next consider the treatment at the time of, and subsequent 
to, tubal rupture or abortion. Here, again, we must consider two 
classes of cases depending on whether the rupture is intraperitoneal 
or extraperitoneal. If intraperitoneal rupture has occurred, most 



ECTOPIC GESTATION. 541 

electro-therapeutists agree that the time for their method of treat- 
ment has passed, and it is the consensus of opinion that there is 
now but one proper treatment — viz. coeliotomy and removal of the 
lacerated tubal sac. We do not mean to say that every case is fatal 
at its first hemorrhage. Many cases prove the contrary, and in the 
hands of careful observers it may be good practice, if the patient is 
improving in pulse, to wait till she has rallied from the shock of the 
initial hemorrhage before operating. The safest rule, however, is to 
prepare at once for operation. 

Just a word as to the method of procedure. Strict asepsis is a 
matter of great importance. The gestation-products and the effused 
blood at the time of or soon after rupture may be considered 
aseptic ; at the same time they form a medium very easy to infect. 

On making the incision in the median line down to the peri- 
toneum the latter is often found tense and dark,- and at the first 
nick of the peritoneum fluid blood may well up in great abun- 
dance. No attention must now be paid to the blood already in the 
peritoneal cavity, but the source of the hemorrhage, the lacerated 
tubal sac, is to be seized at once, ligated, and removed. Not infre- 
quently it may be advisable to remove the opposite appendage and 
the uterus at the same time. The manipulations necessary for the 
removal are the same as those described in the article on Pelvic 
Inflammation. The same structures are dealt with, and, as a rule, 
the tubal pregnancy is complicated by adhesions, just as is the case 
in pus-tubes. We now have time to remove the blood-clots and 
products of conception, which are probably free in the abdominal 
cavity. Large clots and masses are removed by the hand ; the re- 
mainder may either be floated out with the irrigating fluid, boiled 
water (preferably containing a half-teaspoonful of common salt to 
the pint), or, what is often sufficient, the blood may simply be re- 
moved by sponging. Too much time must not be spent in attempt- 
ing to remove every blood-clot. Let the pelvis be sponged and the 
abdomen closed. Unless infection has occurred or oozing from vas- 
cular adhesions is pronounced, drainage is unnecessary. 

If the patient has lost a large amount of blood and the pulse is 
very feeble, some of the irrigating saline fluid may with advantage 
be left in the abdomen ; also a saline enema containing stimulants 
may be administered. The question of infusion may have to be 
decided. 

Extra-peritoneal Rupture. — If this event has occurred, as deter- 



542 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

mined by the physical signs given under Pelvic Hematoma — viz. 
the circumscribed tumor, the lateral fixed position, stricture of the 
rectum, etc. — the treatment is usually non-operative. The patient 
should be kept quiet in bed and cold in the form of ice-bags applied 
to the abdomen, while the progress of the case is carefully watched. 
In the majority of cases the pelvic hematoma thus formed will 
gradually be absorbed. There are, however, three possible indica- 
tions for a future operation : 

1. If the hematoma suppurates; 

2. If repeated hemorrhages occur into the sac ; 

3. If fetal life continues. 

Occasionally, through infection from the rectum or from the 
uterus through the stump of the lacerated tube, suppuration of the 
hematoma occurs : it is then to be incised through the vagina, washed 
out, and thoroughly drained. If repeated hemorrhages are added 
to this hematoma, two courses are open, according to the size of the 
tumor. If comparatively small and situated low in the pelvis, it 
may be incised through the vagina, the clots and debris removed, 
and the cavity drained. If large and extending high in the pelvis, 
coeliotomy is probably the better operation. The broad ligament is 
incised and the blood-clots and products of conception are removed. 
If the contents of the sac appear aseptic, the sac may be sponged 
out and then closed. 

If for any reason the contents of the sac seem open to the sus- 
picion of sepsis, the sac had better be stitched to the lower portion 
of the abdominal wound and drained. A vaginal opening into the 
sac, where practicable, will favor drainage and shorten convalescence. 

Fetal Life Continuing. — In the rare condition where fetal life 
survives the tubal rupture new problems present themselves. We 
have seen above that in almost all cases this only happens when the 
rupture is extra-peritoneal, between the folds of the broad ligament. 
From the time of tubal rupture until the ectopic fetus has reached 
the period of viability it is to be regarded as a foreign body endan- 
gering the life of the mother, and the indication for its removal is em- 
phatic. After the fetus has reached a viable age its life has some 
claims upon the surgeon, but from the fact that ectopic fetuses, even 
if allowed to reach full term, are usually frail and few reach adult 
life, as well as for other obvious reasons, it must be borne in mind 
that the claims of the fetus are always secondary to those of the 
mother. After the seventh month, if the circumstances are such 



ECTOPIC GESTATION. 543 

that the mother can be carefully watched by one competent and 
prepared to operate promptly in case untoward symptoms present 
themselves, it may be justifiable to wait a few weeks and allow the 
fetus this additional time for growth and development. Each case, 
however, must be judged by itself. To wait until pseudo-labor 
has passed and the child is dead is neither scientific nor surgical. 

Having prepared for operation, an incision is made well to one 
side of the median line, so as carefully to avoid opening the perito- 
neal cavity ; the fetal sac is incised and the fetus is extracted. The 
chief point at issue in the whole treatment of a living ectopic fetus now 
presents itself: How shall we deal with the placenta? Whenever 
it is possible to ligate in advance the vessels supplying the fetal sac 
and the patient is in good condition, the best procedure is the com- 
plete removal of the sac and placenta even if the uterus has to be 
removed at the same time. When, however, the placenta lies in 
intimate vascular connection with all the important structures 
at the bottom of the pelvis, most operators are agreed that the 
safer method is to stitch the fetal sac into the abdominal incision, 
pack the sac with gauze, and wait until the placenta separates. The 
sac is then kept open and as clean as possible until it closes from 
the bottom. When the operation discloses the fact that the fetus 
has been dead for some time, the placenta is, as a rule, only loosely 
attached, and can be separated with very little danger of hemor- 
rhage. In such cases the placenta is removed and oozing is con- 
trolled by gauze packing. 

There is one other condition the treatment of which requires con- 
sideration — viz. interstitial pregnancy with intraperitoneal rupture. 
Although rare, this condition needs prompt surgical interference 
if the patient is to be saved. The treatment is abdominal hys- 
terectomy. 



DISEASES OF THE OVARIES, INCLUDING TUBAL ANOM- 
ALIES AND BROAD-LIGAMENT CYSTS. 



Anatomy and Physiology of the Ovary. 

The ovaries in the human female are situated, one on each side 
of the uterus at the level of the brim of the true pelvis, in the pos- 
terior fold or leaflet of the broad ligament. The other two leaflets 



Fig. 301. 




Horizontal Section of the Abdomen immediately above the Crests of the Ilii : B, fundus of bladder; V, 
uterine body; 0, ovary ; L, round ligament ; T, Fallopian tube ; V, sacrum ; R, rectum ; C, utero-sacral 
ligaments ; g, ureter. 

of the ligament are formed superiorly by the Fallopian tube and 
anteriorly by the round ligament. When the woman is in the erect 
position and the uterus in its normal situation, the ovary lies upon 
the ligament and looks upward and backward. The ovary is about 
an inch and a quarter long, three-quarters of an inch in width, and 
half an inch thick, convex upon the posterior and flattened upon 
the anterior surface, resembling in shape and size an almond ; the 
external extremity is blunt and rounded, the internal pointed, pro- 



DISEASES OF THE OVARIES. 545 

jecting toward the ovarian ligament. It is connected with the 
uterus by the latter ligament, which is about one inch long. 

The normal ovary weighs from ninety to one hundred and thirty- 
five grains. It is but partially covered by peritoneum, as is demon- 
strated by the contrast between the columnar epithelium of its pos- 
terior surface and the pavement epithelium of the peritoneum. The 
ovary consists of an external cortical portion, composed of cellular 
elements, and an internal medullary or fibrous portion, through 
which the blood-vessels, lymphatics, and nerves are distributed. 
The blood-vessels and nerves enter through the lower portion, 
which is called the hilum. 

At the fourth month of intra-uterine life the germinal epithelium 
and the stroma undergo a process of adhesion, by which masses of 
epithelium are aggregated in the stroma, forming tubes. Some of 
these tubes possess outlets to the surface of the organ. Some cells 
in the tubes early attain to considerable size, have a nucleus, and 
form the ova. The ova become isolated, and by further prolifera- 
tion of cells acquire a receptacle — the Graafian follicle. The germi- 
nal epithelium is divided by vascular stroma into two layers — an 
outer, composed of thin columnar cells, with one or two rows of 
round cells, which contain primitive ova, and an inner, thicker 
stroma between two layers of cells, which subsequently forms the 
tunica albuginea. 

The ovum originally consists of a nucleus and nucleolus, with a 
small amount of protoplasm. It is never situated in the centre of 
the follicle, but occupies the side most distant from the surface of 
the ovary. The number of ova in an ovary have been estimated 
as numbering from 36,000 to 400,000. It is evident that Nature 
has made provision for the loss of a large number in a rudimentary 
form. 

The formation of ova and egg-balls terminates with fetal life, 
but the isolation of the ova and transformation of egg-balls into 
follicles may be continued a couple of years later. 

The blood-vessels of the ovary are derived from the ovarian 
artery, analogous to the spermatic in the male, which comes off 
from the aorta. It anastomoses with the uterine, a branch of the 
internal iliac artery. 

The right ovarian vein enters the inferior vena cava at an acute 
angle and is supplied with a valve. The left enters the left renal 
vein at an angle and is without a valve. To this anatomical fact is 

35 



546 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



attributed the greater relative frequency of disease of the left ovary. 
The nerves enter the hilum as two fine twigs from the ovarian 
plexus. 

Puberty. — At birth the ovary is flattened and elongated. As 
puberty approaches it assumes an olive shape, which indicates the 
sexually mature female. This period is characterized by the advent 
of the intermittent discharge known as menstruation, supposed to 
be synchronous with ovulation. That these processes are not neces- 




Ut, uterus ; 0, ovary ; Oa, infundibulum and abdominal aperture of the Fallopian tube and fimbriae ; Fo, 
fimbria attached to the ovary ; Po, parovarium ; io, marginal fold of broad ligament continued on to 
the infundibulum (infundibular ovarian ligament) ; ip, the same fold connecting the former with the 
pelvis ; Od, isthmus of the Fallopian tube ; Od', ampulla ; *, fimbrio-ovaric groove, lined by mucous 
membrane covered by ciliated epithelium ; LI, muscular striae under posterior layer of broad ligment ; 
Lo, muscular utero-ovarian ligament. 

sarily interdependent is evident from the fact that women become 
pregnant before the first occurrence of the menses, and, indeed, 
some have given birth to several children without ever having 
menstruated. Numerous cases are upon record where women have 
become pregnant after the occurrence of the menopause. 

Puberty generally takes place between the thirteenth and fif- 
teenth years. A well-established corpus luteum has been found in 
the ovary of a child which died at nine years. 

While it is indisputable that ovulation may occur without men- 
struation, it is to be doubted, notwithstanding the views of Tait, 
whether menstruation ever takes place in the absence of both of 
the ovaries. The cases in which menstruation has continued after 
the ovaries were removed are those in which a portion of the ovarian 



DISEASES OF THE OVARIES. 



547 



stroma was overlooked where it extended downward upon the ovarian 
ligament, or accessory ovaries were present, or there were tufts of 
ovarian stroma spread over the adjacent pelvic peritoneum. 

The mature human ovum measures ^ of an inch in diameter. 
It is provided with a germinal vesicle which has a diameter of ^ 




Section of Ovary. 

of an inch, and within it a germinal spot whose diameter is -^q of 
an inch. As the ovum matures it moves from the centre to the 
periphery of the follicle ; induced by the secretion of liquor folliculi 
contained in its discus proligerus, it is impelled against the thinned 
wall. This wall consists of two layers — an outer, the stroma of the 



Fig. 305. 





Typical Corpus Luteum, fi 
beginning of me 



Freshly ruptured Follicle, twenty days after the 
'beginning of the last menstruation. 



ovary, and an inner, the follicular epithelium. The ovisac is most 
vascular at the point of rupture, and as the ovum escapes into the 
peritoneum or oviduct the ruptured vessels bleed and fill up the 
space with a clot. This clot, as it contracts, becomes known as the 
corpus luteum. If fecundation of the ovum has occurred, the act 



548 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



of conception leads to greater vascularity and the formation of a 
large clot, designated the true corpus luteum to distinguish it from 
the false or small, less durable formation of ordinary unfecundated 
ovulation. 

The true corpus luteum is largest about the eleventh week, and 
continues to the end of pregnancy. The false rapidly becomes 
smaller and presents a bright and shining centre. The successive 
rupture of matured follicles leaves cicatrices upon the surface of 
the ovary. 

Fallopian Tube. — Projecting from each side of the fundus of the 
uterus, just posterior to the round ligament, and occupying the 
superior fold of the broad ligament, is the Fallopian tube. Its 
average length is about four inches, and its greatest width is at the 
outer extremity, called the fimbriated extremity, infundibulum, or 
morsus diaboli. Its orifice is called the ostium abdominale, and is 
surrounded by four or five large and eight or ten small fimbriae, 
which are continuous with the mucous lining of the tube, and one 
of which, the fimbria ovarica, extends to the ovary. The narrow- 




Transverse Section of the Fallopian Tube of a Macaque Monkey. 



est portion of the tube is the inner or uterine end, an inch long,, 
which is known as the isthmus. Its orifice is called the ostium 
internum. The diameter of the isthmus varies from one-twelfth 
to one-sixth of an inch, while the diameter of the ampulla, or outer 



DISEASES OF THE OVARIES. 



549 



portion of the tube near the ostium, is from one-fourth to one-third 
of an inch. At its origin the tube is directed upward and backward; 
the ampulla curves upon itself until the infundibulum or fimbriated 
extremity is directed toward the ovary. The fimbria ovarica has 
upon its upper surface a groove bordered by small fringes or fim- 
brise. Along this furrow passes the ovum to the oviduct as it 




Recess of the Tubal Mucous Membrane of the Panoliau Deer. 



escapes from the ovary, doubtless facilitated by the current pro- 
duced by the wave-like motion of the cilia. 

The Fallopian tube has three coats or layers — the peritoneum, 
which does not completely encircle it, forms the mesosalpinx ; the 
muscular consists of longitudinal and circular fibres; the internal 
coat consists of the mucous membrane. The latter contains no glands, 
and is thrown into longitudinal furrows and projections. Comparison 
of Figs. 306, 307, and 308 shows that the arrangement of the folds of 
the tube in the lower animals is much more complex than it is in the 



550 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

human female. These folds possess the characteristics of glandular 
structure. The membrane is lined with ciliated columnar epithe- 
lium. " The function of the latter," says Tait, " is to expedite the 
passage of the ovum to the womb, and to limit the opportunity for 
entrance of the spermatozoa." This theory obligates conception, as 
a rule, to occur in the uterus, but the repeated occurrence of ectopic 
gestation, in cases in which careful examination has failed to dis- 
close any abnormal condition of the membrane between the gesta- 
tation-sac and the uterus, goes far to discredit the theory. 

The most important change taking place at puberty is in the 
structure of the tube. It becomes more vascular, its muscular 
structure is developed, and the epithelial layer is fully formed. 
These changes result in the functional movement through which 

Fig. 308. 




Transverse Section of the human Fallopian Tube. 

pregnancy is rendered possible. As has already been noted, ovula- 
tion has repeatedly occurred prior to puberty, but the ovum has 
been lost in the peritoneal cavity. Ovulation may continue after 
the menopause, though the ovaries have become atrophied, but the 
tubes will then have become straightened, and again fail to carry 
the ovum to the uterine cavity. 

The ovary and tube are situated in the folds of the broad liga- 
ment, the superior fold being occupied by the latter. The ligament 
is continued to the ileo-pectineal line by the infundibulo-pelvic liga- 
ment. Between the tube and ovary, and within the fold of the 
broad ligament, is an embryonal body, which consists of a number 
of small tubes and cysts, and is known as the parovarium or organ 
of Rosenmuller. It is most probably the remains of the Wolffian 



DISEASES OF THE OVARIES. 551 

body. The tubes of which this body is composed sometimes ex- 
tend into the hilum of the ovary, and thus afford, according to 
some authorities, a congenital source of origin for some forms of 
ovarian cyst. A small, thin-walled cyst, known as the cyst or 
hydatid of Morgagni, hangs from the posterior surface of the 
Fallopian tube by a long pedicle. It has no pathological sig- 
nificance. 

Malformations of the Ovary and Tube. 

Congenital absence of both ovaries occurs but rarely. When 
this malformation occurs, it is generally associated with defective 
development of the uterus. In such patients the physical changes 
in conformation incident to puberty do not occur, and the individual 
more closely resembles in appearance the male. When one ovary 
is absent, there is likely to be a deficiency in the development in the 
corresponding half of the uterus and tube. In a number of cases 
there has also been an absence of the corresponding kidney. A 
third or accessory ovary is very infrequent. 

Doran asserts that small fibro-myomata in the ovarian ligament 
have been mistaken for supernumerary ovaries. Small islets of 
ovarian tissue have been found upon the peritoneum. Such a con- 
dition or the incomplete removal of an ovary undoubtedly has 
been the cause of menstruation subsequent to oophorectomy. 

Where the ovaries are absent or marked failure in their develop- 
ment has occurred, the sexual functions are never performed nor- 
mally. The absence of one ovary or its serious involvement by 
disease constitutes no obstacle to either sexual intercourse or con- 
ception. It is very important to determine, if possible, that the 
ovaries are absent or rudimentary, as when these conditions are 
once recognized the absolute futility of any measures to establish 
menstruation is demonstrated. 

Malformations of the Tubes consist chiefly in defective de- 
velopment of the fimbriae at their abdominal ends. The tube may 
be unusually short or have supernumerary ostea or openings. These 
openings may be provided with fimbriae or the latter may be absent. 
An unusually convoluted tube is sometimes observed, evidently due 
to its defective development, resembling the condition seen in women 
prior to puberty. At times the convolutions of the tube form actual 
strictures, which contract its cavity sufficiently to render the woman 
sterile. 



552 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

Displacements of the Ovaey and Tube. 

Hernia through the inguinal canal is a rare condition. It is 
generally found upon the left side. Hernia of the ovary may 
occur without the presence of any other organ in the hernial sac, 
unless it be the Fallopian tube. The presence of the ovary is 
generally secondary, however, and results from adhesions to the 
omentum and the intestines. 

Most probably the first surgical removal of the ovaries was per- 
formed by Potts for ovarian hernia. The displaced organs may 
readily be mistaken for glands or labial tumors. The constant 
presence of a tumor, its physiological character, the dull, sickening 
pain, and extreme nausea, should aid in the diagnosis. The ovary 
has also been known to make its exit through the crural canal, the 
greater sacro-sciatic foramen, and the umbilicus. Such displaced 
organs may become cystic. Chenieux has reported a cyst of this 
variety in the right buttock which was mistaken for a lipoma. 

Treatment. — Taxis should be judiciously and carefully exer- 
cised, the ice-bag or the sand-bag may be applied, and after reduc- 
tion has been effected a truss should be worn. If the symptoms are 
annoying and reduction cannot be accomplished, the sac should be 
incised and the ovary replaced or removed, according to its condition. 

Prolapsus Ovarii. — Displacement of the ovary may be depend- 
ent upon, or independent of, the position of the uterus. When the 
latter organ is retroverted or -flexed, the ovary is no longer sup- 
ported upon the broad ligament, but hangs from it. The ovary may 
rest in front of the uterus, but it generally lies beneath that organ 
in the cul-de-sac. The ovary may be displaced, while the uterus 
retains its normal position. The left ovary is most frequently dis- 
placed. 

The prolapsed organ is exceedingly tender, and is the cause of 
dysuria, dysmenorrhea, and pain during coition and defecation. 
The pain during and following the marital act may be so great as to 
preclude its performance. The paroxysms may continue for more 
than an hour subsequent to defecation. 

Etiology. — Prolapsus is generally a sequel of gestation ; the 
broad ligament becomes extended and the infundibulo-pelvic liga- 
ment may give way. Enlargement of the ovary from chronic 
inflammation or perimetritis may be important factors. 

Diagnosis. — By vaginal and rectal palpation a mass is deter- 



DISEASES OF THE OVARIES. 553 

mined which when movable can be displaced upward, or whose pedicle 
can be recognized when the tumor is pressed downward. It is ex- 
ceedingly sensitive, and pressure upon it causes a peculiar sickening 
sensation, similar to that produced by pressing an inflamed testicle. 

In displacements complicated by severe inflammation the ovaries 
and tubes may be fixed behind the uterus. 

Treatment.— The first consideration should be rest. The bowels 
must be carefully regulated and the marital relation be absolutely 
prohibited. The patient may be placed in the genu-pectoral posi- 
tion and the organs pushed up and maintained by a suitable pessary. 
The reinforced pessaries prove the most satisfactory, as their thick- 
ened posterior bar affords more efficient support and decreases the 
possibility of the organ being pinched between the pessary and the 
sacrum. The occurrence of this accident is attended with agonizing 
pain, rendering the patient unable to move until the pressure is 
removed. When various pessaries have been unsuccessfully tried, 
and the patient is incapacitated for her duties, abdominal section 
should be performed, and ovarian fixation effected, either by restor- 
ing the infundibulo-pelvic ligament or suturing the pedicle of the 
ovary to that part of the anterior parietes corresponding to the exit 
of the round ligament. This operation may be associated with 
ventro-fixation of the uterus, when retroversion of that organ com- 
plicates the displacement. Descent of the ovary alone never justi- 
fies extirpation. The latter procedure should only be considered 
when the displacement is associated with marked oophoritis or peri- 
oophoritis. 

Congestion of the Ovaeies. 

The ovaries are physiologically congested in ovulation and dur- 
ing coition. This congestion in excess or prolonged becomes patho- 
logical. An over-congestion of the ovaries is not infrequent at the 
establishment of the menstrual function, especially in individuals in 
whom the mental faculties have been developed at the expense of 
the physical structure. Girls are often too closely confined to school 
and to the study and practice of music when Nature requires her 
forces in order to secure perfect development. Blood may extrava- 
sate into the follicles and stroma of the ovary, more frequently into 
the former. The hemorrhage into the follicles may distend the 
ovary to the size of a hen's egg or even to that of an orange. Later, 
this is converted into a pigment the consistency of honey, having a 



554 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

rusty chocolate color. Winckel has reported similar conditions 
associated with heart disease, typhoid fever, phosphorus-poisoning, 
and in extensive burns. The follicle generally does not rupture, 
but the ovarian tissue is completely destroyed. A case came under 
the observation of the author in which each ovary was distended to 
the size of a small orange, and consisted of thin-walled cysts filled 
with dark grumous blood. Follicular apoplexy, as well as ovarian 
congestion, generally occurs in the sexually immature. It may 
terminate in absorption, or the ovary may rupture and a large 
hemorrhage take place into the peritoneal cavity, causing fatal 
peritonitis. 

The principal symptom of congestion of the ovary is pain in the 
lateral regions of the pelvis for a week or ten days prior to the 
appearance of the flow, which becomes less or disappears with its 
cessation. The escape of blood relieves the engorged organs, and 
the only period of comfort is experienced during menstruation. The 
flow is prolonged and excessive, frequently amounting to a hemor- 
rhage. The patient becomes weak, pale, and anemic. 

Diagnosis. — The existence of this condition should be suspected 
from the age, near puberty, the excessive and prolonged flow, 
anemic appearance, weakness, pain, and tenderness within the pelvis 
— which is generally more marked upon the left side — and not 
infrequently pain in the corresponding mammary gland. Follicu- 
lar apoplexy is rarely recognized, as it presents no distinctive 
symptoms. 

Termination. — Ovarian congestion under proper hygiene and 
treatment may disappear. Where it continues it is transformed 
into chronic inflammation. The collections of blood in follicular 
hemorrhage may be absorbed, leaving an enlarged cicatrix, or they 
may break down and destroy the ovarian structure, forming an 
ovarian hematoma. Extensive hemorrhage with rupture of the 
ovary may cause pelvic hematocele, or even death. 

Treatment. — Attendance upon school, and particularly the 
study of music, should be discontinued ; the reading of emotional 
literature interdicted; and out-door pursuits encouraged, such as 
horseback and bicycle riding and walking. City girls should be 
sent to the country or sea-shore. Regular action of the bowels 
should be secured, and a generous diet afforded, from which sweets 
and pastry must be largely excluded. A morning sponge-bath, fol- 
lowed by friction with a coarse towel, will be serviceable. Rest in 



DISEASES OF THE OVARIES. 555 

bed for a few days prior to and during the entire menstrual period 
should be the rule. If the flow is excessive, the period should be 
preceded for a few days by the administration of one of the follow- 
ing remedies : fluid extract of ergot sss,. ergotine gr. ij in capsule, or 
a capsule or tablet triturate of hydrastinin, gr. \ to \, three times 
daily. During the menstrual intervals potassium bromide, gr. xv, 
or potassium chlorate, gr. v, administered three times daily, with 
such tonics as quinine, strychnine, and the bitter tinctures should 
be given. 

The anemia may tempt one to resort to the use of the salts of 
iron, but experience teaches that this remedy is of service only after 
the tendency to hemorrhage has ceased. Its earlier administration 
but aggravates the tendency to bleeding. 

OoPHOEITIS AND PERIOOPHORITIS. 

Inflammation of the ovary may be acute or chronic. Anatomi- 
cal distinctions of parenchymatous, follicular, and interstitial are 
made, but such distinctions are rarely determined clinically. 

Acute Oophoritis. 

In acute inflammation the ovary becomes enlarged, filled with 
cysts, or is oedematous ; the cysts are filled with a cloudy serum 
looking like pus. The ovary may in a few days become three 
or four times its normal size. The cut surface will exude a 
large quantity of serous fluid, while in more severe grades a 
number of purulent yellow streaks will be seen starting from the 
hilum. A smeary mass will be discharged in some cases, while in 
others there will be the distinct pus-collection of an abscess. The 
organ may attain to the size of a man's head, though generally it 
is not larger than a hen's egg, when it produces the sensation 
to the examining finger of a firm mass. An inflammation of 
the ovary may progress to the formation of abscess, and subse- 
quently the watery contents be absorbed, leaving a cheesy mass. 
In the milder forms of inflammation resolution may take place. 
The connective tissue undergoes retraction, depressing the surface 
here and there, producing premature involution or cirrhosis of 
the ovary. The ovary may be reduced to the size of a hazel- 
nut. This form of inflammation is prone to affect both ovaries, 
while the abscess is usually found in but one. In perioophoritis 
the capsule of the ovary becomes thickened ; the entire organ is 



556 AN_ AMERICAN TEXT-BOOK OF GYNECOLOGY. 

bound down by perimetric bands of adhesions. The thickening of 
the capsule renders it less likely to rupture with the ripening of the 
Graafian follicle, and a small cyst remains. Under the influence 
of disturbed circulation a large number of follicles may mature at 
once, producing a cystic ovary. The partitions frequently break 
down, and a large cyst is formed. 

Etiology. — The principal causes of acute oophoritis are — injury, 
septic poisoning after parturition or abortion, gonorrhea, arsenical 
or phosphorus-poisoning, the exanthemata, acute rheumatism, and 
long-continued endometritis. 

Sepsis, without doubt, is the most frequent cause ; the next 
frequent is gonorrhea. Septic inflammation is very likely to 
result in abscess and a more or less extensive peritonitis. The 
left ovary is more prone to be the seat of such a destructive pro- 
cess, due, according to some authors, to the difference in its circu- 
lation. Gonorrhea produces perioophoritis with a binding down 
of the ovary by adhesions. 

Symptoms. — The patient complains of intense, lancinating pain, 
generally over the left inguinal region, associated with extreme ten- 
derness, elevated temperature, rapid pulse, and frequent chills. In 
perioophoritis the symptoms are less marked than are those of mild 
peritonitis. 

Coukse and Termination. — Acute oophoritis may terminate in 
resolution and disappearance of the abnormal symptoms, the devel- 
opment of an abscess, its rupture, and the occurrence of a rapidly- 
fatal infective peritonitis, or the disease may become chronic. 

Treatment. — The treatment should consist in absolute rest in 
bed, the administration of salines until free purgation is secured. 
Tincture of aconite, gtt. j-ij every hour, is of value. Leeches may 
be applied to the perineum and an ice-bag to the seat of pain, or, 
where better borne, hot fomentations with opium, morphine given 
by the rectum, or where pain is very severe the morphine may be 
given hypodermically. When an abscess forms, the only acceptable 
treatment is surgical, as considered in the chapter on Pelvic Inflam- 
mations. 

Chronic Ovaritis. 

Chronic inflammation is much more common than the acute dis- 
order. It occurs during the period of sexual activity, and more 
frequently in the married. The ovary may be enlarged, presenting 



DISEASES OF THE OVARIES. 557 

a number of cysts with little interstitial growth or increase of the 
fibrous tissue of the organ ; subsequent atrophy, known as cir- 
rhosis, occurs. The ovary may be fixed in the pelvis by an 
extensive infiltrate, so that it is immovable and scarcely to be 
distinguished, or it may be movable and prolapsed into the retro- 
uterine pouch. 

Etiology. — Chronic ovaritis may be the sequel of the acute 
disease and due to the same causes. It is produced also by exces- 
sive sexual intercourse, masturbation, sexual excitement without 
gratification, suppressed menstruation, and to operations upon the 
cervix. 

Symptoms. — Pain is an inevitable feature, experienced with the 
greatest intensity in the groin and with the greatest frequency upon 
the left side. It is persistent, increased by locomotion, by a misstep, 
or by jolting. It is greatly exaggerated as the menstrual period ap- 
proaches. If the flow is free, amounting to a menorrhagia, the pain 
is relieved or may disappear ; if it is but slight, the pain increases. 
When the pain from any cause is intensified, it extends down the 
thighs and over the sacrum. Not infrequently pain is felt in one 
or both mammary glands of such intensity as to lead the patient to 
suspect the existence of malignant disease. Symptoms of spinal 
irritation and attacks of migraine are frequent near the menstrual 
periods. Hysteria or hystero-epilepsy may be an accompaniment. 
Sterility is an almost constant result. The ovaries are generally 
tender to pressure, though they may not be to any considerable 
degree enlarged. When prolapsed behind the uterus with that 
organ resting upon them, they are sensitive to the slightest pressure,, 
and cause pain in defecation, and especially in coition. Frequently 
the marital relations are so painful and produce so much distress 
that they .are necessarily discontinued. Physical examination must 
be conducted with great care. When the organs are prolapsed and 
fixed behind the uterus by inflammatory exudate, the careless 
observer may mistake the condition for retroflexion of the uterus. 

Diagnosis. — The determination of large and sensitive ovaries, 
exaggerated distress for a week or ten days prior to menstruation, 
mammary pain, with painful defecation and coition, leave but little 
room for doubt, When the physical signs obtained by vaginal 
touch are obscure, rectal examination will be of great service and 
should be a routine practice. Where the abdominal walls are 
rigid or the pelvic organs very sensitive, an examination under 



558 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



anesthesia may be of value in supplementing or confirming the 
diagnosis. 

Treatment. — Where it is possible, the removal of the sources of 
irritation which have led to the production of the disease should be 
the first consideration. The marital relation should be suspended 
or infrequently practised ; vigorous exercise or long standing upon 
the feet should be avoided. The patient should rest in bed during 
menstruation. Blood may be abstracted by leeches to relieve 
severe pain. Counter-irritation with iodine, blisters over the 
region of the ovaries, or mercurial inunctions may be beneficial. 

Internally, the administration of the potash salts, as the iodide, 
bromide, or chlorate, alone or in association with the bitter tonics, 
as nux vomica and cinchona or their alkaloids, strychnine or 
quinine, often give marked relief. 

Benefit has been claimed from the following : 



Si 



fy. Auri et sodii chloridi, 

Extractum cannabis indicse, 
Ft. cap. 
». Take one capsule three times daily. 



gr. ss.- 



-M. 




Diagram of the Structures in and adjacent to the Broad Ligament : 1. la, multilocular cystic tumor, devel- 
oped in 1, parenchyma of the ovary : :'., papillomatous cystic tumor of the ovary in 2, tissue of the 
hilum of theovarv'; 1, simple broad-ligament cyst, independent of the parovarium, 1(1, and the Fallo- 
pian tube; 5, a similar cyst, in the broad ligament above the tube, hut not connected with it; 6, a similar 
cyst close to 7, ovarian fimbria of the tube : s, hydatid of Mm^igni (this never appears to form a large 
cyst); 9, cyst developed from the horizontal tube of the parovarium; 11, cyst developed from a ven- 
tricle tube I cysts of Ibis kind form t lie papilloma! mis tut ■» of the broad ligament); 12, 13, tract of 

the obliterated duct of Gaertner (papillomatous cysts are said to be developed along this tract). 



Ichthyol has frequently been found of service; its beneficial 
influence may be secured by administration by the mouth, by sup- 
pository, either vaginal or rectal, and through abdominal inunc- 



•2_ -'• p J 



O M H 



g P. C= 




I 



DISEASES OF THE OVARIES. 



559 



tion. Fixation of the ovaries may be overcome by the judi- 
cious use of pelvic massage. The severity of the attacks of pain may 
be much ameliorated by the administration of ten drops of tincture 
of pulsatilla, four times daily preceding the expected attack, and 
continuing it until the menstrual flow has been well established. 
In severe cases, or where all palliative measures have failed to 
ameliorate the distress, and the general health is being gradually 
undermined, the offending: organs should be removed. 



Ovaeian Neoplasms. 

The neoplasms of the ovary may be divided clinically into cystic 
and solid growths. The cystic tumors include simple, proliferating, 
and dermoid cysts. The solid tumors are fibromata, sarcomata, and 
carcinomata, and are comparatively rare. Cysts may originate in any 
part of the tubo-ovarian structure, as the cortical, medullary, or paren- 
chymatous structure of the ovary ; in its inferior border or hilum ; in 
the structures between the tube and ovary known as Rosenmuller's 
organ or the parovarian structures ; and in the hydatid of Morgagni, 
the extremity of the canal of Muller. Cysts are developed also in 
the folds of the broad ligament, and are known as broad-ligament 
cysts. The cysts may be unilocular with limpid contents, or multi- 
locular with contents varying in different cysts, some clear and 

Fig. 310. 




Broad-Ligament Cyst, Fallopian Tube and Ovary. 



limpid, others thick and viscid or discolored with the admixture of 
blood, pus, or fat. The broad-ligament cysts are generally unilocu- 
lar, containing clear fluid ; those originating in the hilum, papillary ; 
and in the parenchymatous tissue of the ovary, glandular. 



OGO AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

The cysts may be divided pathologically into simple, proliferating, 
dermoid, and parovarian, or, according to size, into small and large- 
cysts. 

Under small cysts may be described, first, small residual cysts 
developing from Morgagni's hydatid or the horizontal canal of the 
parovarium ; second, follicular ; third, cysts of the corpus luteum ; 
and fourth, tubo-ovarian cysts. 

The large cysts include, first, the glandular proliferous; second, 
the papillary proliferous ; third, dermoid, simple or mixed ; fourth, 
parovarian, including several varieties, as hyaline, papillary, and 
dermoid. 

Cysts of the Hydatid of Morgagni. — Attached to the fimbriated 
end of the Fallopian tube is generally found a cyst varying from 
the size of a pea to that of a cherry. It is transparent and has a 
thin wall. This hydatid is the remains of the extremity of Miiller's 
canal, and is rarely absent. The length of its pedicle varies in dif- 

Fig. 311. 




Cyst of the Organ of Morgagni. 

ferent individuals. It is sometimes nearly an inch in length, and 
very thin ; in other cases it is short and thick. Doran describes a 
supra-tubal cyst about the size of the former and of the same ap- 
pearance and structure. It is supposed to be a micro-cyst of the 
broad ligament which has slipped under the serous membrane and 
attained this unusual position. 

Micro-cysts of the Broad Ligament. — These are small cysts which 
develop in the structure or are suspended from Rosenmiiller's organ : 
other cysts are found free and are of undetermined origin. Only 
those which originate from the vertical tubes of the parovarium 
have ciliated epithelium, and are likely to subsequently develop into 



DISEASES OF THE OVARIES. 561 

papillary growths. The others, and even those which start in the 
horizontal tube, may become detached from the broad ligament and 
hang by a slender pedicle. These micro-cysts may possibly be the 
starting-points for large cysts with either fluid or papillary contents. 

Simple or Follicular Cysts. — These cysts are formed from unrup- 
tured Graafian follicles which become dilated. In an ovary which 
has not attained to twice its normal size may be found fifteen or 
twenty of these cysts. They were long considered as the only 
source of large ovarian cysts. It has, however, been discovered that 
it is only in rare cases that they attain to the size of a fist, or at the 
utmost to that of a man's head. They contain a light serous fluid 
with a specific gravity of 1005 to 1020. The cyst-wall is thin, has 
a light-gray color, and is in large part a transparent membrane. 
The disease is generally bilateral. 

Etiology. — These cysts, even when of large size, are regarded 
as dilated Graafian follicles, because of the different gradations 
observed between them and the smaller cysts. In the smaller size 
ovula may be detected, which may have been destroyed or have 
escaped observation in the larger. 

Dropsy of the follicle is occasioned by its failure to rupture with 
the increase in its fluid contents. The rupture may be prevented 
by its deep situation, thickening of the tunica albuginea, or deposits 
of peritonitic exudation over the surface of the ovary. It may also 
be caused by too slight a menstrual congestion, which, though in- 
creasing the secretion, is insufficient to produce rupture. 

Cyst of the Corpus Luteum. — This cyst was first described by 
Rokitansky, who believed that the corpus, luteum of pregnancy only 
could be transformed into a cyst, but such cysts have been found in 
the nulliparae. They are generally not larger than a walnut, but 
cases have been described in which they have attained the size of an 
orange or an apple. Nagel even speaks of one which had reached 
the size of the adult head. Microscopical examination shows in the 
walls the bud-like papillae characteristic of the corpus luteum. The 
recognition of this prevents their confusion with follicular cysts, or 
even with suppurative ovaritis. 

Tubo-ovarian Cysts. — The presence of an ovarian cyst not infre- 
quently results in the formation of a tubo-ovarian cyst through its 
proximity to a distended tube. Tubal inflammation early results in 
fastening the ostium of the tube to the ovary by firm adhesions. A 
dilated follicle or a small cyst may readily rupture into a distended 



562 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



tube, with which it is in juxtaposition, and form one sac, the smaller 
part of which is generally furnished by the tube. It does not usu- 
ally attain to a large size. The Fallopian tube may remain permeable, 
and as the fluid increases the overflow passes into the uterus ; a con- 
dition known as profluent ovarian hydrops is thus formed. It may 
be compared with the condition engendered by hydrosalpinx known 
as profluent hydrops tubas. The open tube may act as a safety- 
valve, preventing the growth and over-distension of the cyst, 
and in some cases leading to its complete prolapse after every 
evacuation. 



Large Cysts. — Proliferating Cystomata. 

The term " proliferation," as applied to cysts, refers to those which 
are highly organized and abundantly supplied with blood-vessels. 

Fig. 312. 




Large Ovarian Cyst, weighing 149 pounds. 

The term " proligerous cysts " is also applied to them, and indicates 
their faculty of budding and generating new cysts from or within 



DISEASES OF THE OVARIES. 



563 



the original growth. In shape they may be spherical and regular 
in outline, simulating the presence of a single cyst, or irregular, 
presenting nodules, indicating a multilocular tumor. 

They may vary from the size of an egg to that of a tumor weigh- 
ing more than one hundred pounds, filling up the entire abdomen 
and encroaching upon the thoracic viscera. When exposed the 
cysts present a pearly-white, glistening appearance. The thinner 
portions are purple, green, or black according to the color of their 
individual contents. The external surface may be smooth and oily, 
covered with papillary growths or mucous vegetations. The tumor 
generally has a distinct pedicle. The consideration of the internal 
structure of ovarian cysts justifies their division into areolar, uni- 
locular, and multilocular. 

Areolar. — When an areolar cyst is opened it is found filled with 
spurs or trabecule of small cysts which have ruptured to form a 
large main cyst, or it may be made up of a large number of small 

Fig. 313. 




Proligerous Glandular Ovarian Cyst of areolar appearance. 



cysts bound together by loose connective tissue almost gelatinous in 
appearance. In a tumor of this kind, removed from a young 
woman, a large number of small cysts were found. Although the 
tumor was as large as a pregnant uterus at full term, it contained no 
cyst larger than a good-sized plum. 

Unilocular cysts attain to an enormous size, but are found to 



564 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

contain evidences of previous division into smaller cysts, and it 
may be asserted that all unilocular cysts arise from the multilocular : 
even in the large tumors close examination will disclose small cysts 
in their walls. 

Fig. 314. 




Multilocular or Glandular Cystoma. 

Multilocular cysts are so called because they contain a number 
of cysts of nearly equal size, so arranged as to present the appear- 
ance of one large cyst. 

The cyst-wall can be divided into three layers — an outer and 
an inner of fibrous, and a middle layer of connective tissue. In 
the latter the vascular supply is distributed, and it sometimes con- 
tains vessels as large as the femoral vein. In areolar cysts these 
vessels can be seen coursing upon the surface, and when wounded 
may cause dangerous or even fatal hemorrhage. Large vessels are 
frequently found free in the gelatinous contents of large cysts, and 
remain after the destruction of the former septa. Such vessels may 
be the source of hemorrhage into the cyst. 



DISEASES OF THE OVARIES. 



565 



The external surface of the cyst is covered by columnar epithe- 
lium differing from the pavement epithelium of the peritoneum. 
The internal surface is lined by low cylindrical cells. Section of 
the cyst-walls shows depressions of the endothelium resembling 
acinous glands with a narrowed opening. The lining membrane 
may be covered with vegetations formed from proliferated stroma, 
simulating myoma or fibro-sarcoma. These tufts are covered with 
a single layer of endothelium. Epithelial prolongations of a tubular 
form may penetrate from below upward, presenting the appearance 
of carcinoma. 

The contents of the cysts often present marked contrasts in 




Portion of an Ovarian Adenoma, showing the variet 



primary; d, secondary. 



color or consistency; thus they may be found either almost colorless, 
straw-colored, green, purple, or black in color, thin, and thick, viscid, 
or gelatinous in consistency. The contents may vary in color and con- 
sistency in different cysts of the same tumor. The fluid in the smaller 
cysts is generally more consistent and becomes thinner as they increase 
in size, the result of changes in the structure of the epithelium. 



566 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

Proliferating cysts may be divided into two classes : first, those 
in which the vegetations are derived from the epithelium and from 
glandular tubes, proliferous glandular cysts, or adenomata ; second, 
those in which the connective tissue of the walls develops and pro- 
jects as vegetations — proliferous papillary cysts. These cysts do 
not differ essentially in their origin. 

The walls of the cysts may undergo the following degenerative 
or retrogressive processes : 

1. Calcification most frequently take place in the inner layer 
of the main cyst-wall as deposits of granules or small plates of lime 
or the formation of psammatous bodies, as seen in the papillary 
cystomata. The calcification increases with impairment of nutrition, 
as occurs in gradual torsion of the pedicle. 

Fig. 316. 




Calcified Corpus Luteum : A, calcified portion; B, interior of the corpus luteum. 

2. Fatty degeneration occurs in the papillary cells, which are 
regenerated, while the desquamated fatty cells are destroyed. A 
similar change takes place in the connective tissue and walls. The 
process is enhanced by any impairment of nutrition. The pressure 
of cyst-contents induces this change in the septa, resulting in their 
partial or complete destruction. The presence of a large amount of 
fat in the fluids is indicative of slow growth. 

3. Atheromatous changes, which generally take place in the inner 
layer of the wall. 

4. Changes due to infarctions in which whitish opaque bodies 
will be found in the septa surrounded by a red zone. 

Papillary Cystomata. — These cysts were formerly regarded as a 
variety of the glandular. They are believed to have developed from 
the paroophoron, in the broad ligament, or in the prolongations of 
its tumors into the hilum of the ovary. They differ from ordi- 
nary ovarian or oophoritic cysts in that, first, they produce no effect 
upon the shape of the ovary until they have attained a large size ; 
second, they burrow beneath the layers of the mesosalpinx, and 
when of large size separate the layers of the broad ligament beside 



DISEASES OF THE OVARIES. 



567 



the uterus ; third, their interior is filled with warty growths. These 
warts form cauliflower growths, or masses which over-distend and 
rupture the cyst-walls, from which they extend to the adjacent 
organs, particularly the peritoneum. The cysts rarely attain to 
large size, and in the majority of cases are bilateral. 

When the cyst ruptures, the dendritic masses infect the perito- 
neum, producing growths upon the adjacent tissues. These are 






Fig. 317. 




Dermoid Cyst containing long red hair, 



glit haired woman aged 44 years. 



reddish or pearly- white and glistening masses, or in some cases 
growths three or four inches long projecting in every direction 
and having the appearance of stems of coral. These masses have 
usually partly undergone calcification, so that they break easily and 
without bleeding. 

These tumors are characterized by slow growth, by frequent and 
early pressure-symptoms, and generally by the early presence of 
ascites, which soon returns after puncture. 



568 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

The writer lias had a number of cases of the growths under 
observatiou. In a recent one the involvement was bilateral and 
beneath the peritoneum, dissecting it off from the posterior surface 
of the uterus and obliterating the retro-uterine cul-de-sac. A large 
quantity of ascitic fluid was drawn off, when the entire peritoneum, 
parietal and visceral, was found studded with small red masses. In 
another patient the entire surface of the uterus and broad ligaments 
was covered with dendritic masses three inches long, which had 
become partially calcified. Specimens of such growths are repre- 
sented in the illustrations. The danger of peritoneal infection pre- 
cludes tapping when there is any reason to suspect such a growth. 

Ovarian Dermoids. — Dermoid tumors are those in which are 
found skin or mucous membrane associated with the structures 
generally connected with such tissues. The tissues most frequently 
found are hair, teeth, nails, sebaceous and sweat-glands, and mam- 
mae, horn, bone, unstriped muscular fibre, and, in rare cases, a tissue 
resembling brain. The hair varies in color, length, and quantity. 
It is not always of the same color as that of the person from whom 
the tumor is removed. The sebaceous glands are numerous and 
produce an extensive accumulation of fatty material. The teeth 
are irregular, generally imperfectly formed, though presenting the 
structures of dentine and enamel. They vary in number from two 
or three to several hundred. They may dot the surface of a mem- 
brane or be inserted in thin spicula of bone. The bone is gener- 
ally loose, ill-formed, and irregular. 

These growths may appear at any age. They have been found 
in children at birth and in women of ninety years. A tumor 
removed from a girl aged eleven years had been noticed when but 
eight years of age. It involved both ovaries, and the fundus was 
imbedded in the mass. The neck of the uterus was made to form 
the pedicle. The tumor contained a large quantity of sebaceous 
material — hair, bone, teeth — and at one point a mass resembling 
one side of the upper jaw covered with mucous membrane and 
containing a row of teeth. 

The specimen represented by Fig. 317 was removed from a 
woman aged forty-four years, who had given birth to six children. 
It contained hair and sebaceous material. Cullingworth reports a 
woman, in whom both ovaries were apparently involved by der- 
moids, who had given birth to twelve children and had three mis- 
carriages — the last, three months before the removal of the growths. 



PLATE XXXVII. 




M,*i 



, v 

I i* k 



*0 



e. 






# 7 /■' ')'\ S*"V"» 




Dermoid Cyst Laid Open, showing Maxillary Bone containing teeth ; the head of one of the long bones: 
skin with hair growing from its surface; serous membrane (probe passed underneath) ; mucous mem- 
brane of stomach directly next to serous membrane. 



DISEASES OF THE OVARIES. 



569 






The rupture of ovarian dermoids is followed by peritonitis. The 
irritating character of their contents contraindicates puncture prior 
to their removal. The writer has seen a case in which an attempt 
at aspiration was followed by an attack of peritonitis which proved 
fatal, notwithstanding that aspiration was followed three days later 
by ovariotomy. 

Solid Tumors of the Ovary. 

The solid growths of the ovary comprise 5 per cent, of the cases 
which present themselves for operation, and may be divided into 
three groups : the fibro-myoinata, sarcomata, and carcinomata. The 
first, fibro-myomata, are frequently divided into two groups: the 
fibromata and myomata. The former are rare, and comprise those 
growths in which the minute structure consists of wavy bundles of 
fibrous tissue closely packed, intermixed with small round cells. In 
a. few instances these growths attain a large size. Williams described 




Calcified Fibr 



one which weighed seven pounds seven ounces ; Doran, one of seven- 
teen pounds. The myomata are more frequent than the former, but 
are not common. These tumors are prone occasionally to undergo 
calcareous degeneration, and are under these circumstances often 
mistaken for osseous tumors — a variety of ovarian degeneration 
which rarely if ever occurs. 

Unstriped muscular fibre occurs in the ovary as a continuation 
of the ovarian ligament. Tumors of the ovary composed of this 
tissue sometimes attain to a large size. Sutton mentions a specimen 
in the Museum of the Royal College of Surgeons removed from a 
woman aged 68 years, which weighed fifteen pounds two ounces. 



570 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



Sarcomata and Carcinomata are fully described in the chapter on 
Malignant Diseases. 

Parovarian Cysts. 

Cysts of the parovarium may be divided into those which occur 
in the outer series of tubules free at one extremity and known as 
Kobelt's tubes, an inner set of vertical tubules, and lastly a large 
tube running at right angles to the vertical tubes may be occa- 

Fig. 319. 




Showing the Structure of Calcified Fibromata. The darker portions represent areas of calcification. 

sionally traced downward to the vagina. This is Gartner's duct. 
There are two kinds of cysts which arise from the parova- 
rium ; the most frequent are the small pedunculated cysts con- 
nected with Kobelt's tubules, which do not become larger than 
a pea, and consequently have no clinical importance. The most 
important are the sessile, which remain between the layers of the 
mesosalpinx, and as they enlarge burrow into it. In these large 
cysts the Fallopian tube becomes elongated. Small cysts are usually 
transparent; when they become larger than a cocoa nut this appear- 
ance is lost. The fluid is clear, limpid, with a specific gravity of 



DISEASES OF THE OVARIES. 571 

1010 and an alkaline reaction. They are distinguished from the 
ovarian cysts, first, by the ease with which the peritoneal coat can 
be stripped off; second, by the ovary being generally found 
attached to the side of the cyst ; third, by the cyst being unilocu- 
lar ; fourth, by the Fallopian tube being stretched over the cyst 
and never communicating with it; fifth, by the specific gravity 
which does not exceed 1010, and may be lower ; and lastly, in 
the same specimens, by the tissue of the mesosalpinx which be- 
comes gradually thickened. These cysts rarely occur before the 
age of sixteen ; they probably form about 10 per cent, of the 
cysts which are subjected to operation. They generally do not 
form adhesions, and rarely suppurate even when tapped. 

Pedicle. — In all varieties of cysts of the ovary or the broad liga- 
ment the presence, absence, or character of the pedicle is of great 
surgical importance. It may be thin, almost membranous; long 
and narrow, consisting only of the folds of the peritoneum or of 
peritoneum and elongated tube: or may be broad and thick, 
comprising the entire broad ligament. Its length and thickness 
will depend upon the proximity of the cyst to the uterus. The 
pedicle consists of two parts — the ovarian ligament and the Fallo- 
pian tube. 

The thick pedicle may consist of the broad ligament, hyper- 
trophied and reinforced by muscular tissue from the uterus. When 
there is no pedicle the tumor has developed wholly within the broad 
ligament The tumors of the broad ligament, some dermoids, and 
glandular cysts of the ovary are of this class. 

In the recent removal of cysts of this character the peritoneum 
is separated from the posterior surface of the uterus, while the 
tumor dips down upon the left side of the uterus to the roof of 
the vagina, leaving a large membranous cavity. 

Etiology. — Ovarian cysts may occur at any age, and are not 
infrequently found in the fetus. Doran describes fetal ovaries which 
contained cysts yV to } of an inch in diameter, lined with cylindrical 
epithelium and filled with dendritic vegetations. Congenital ovarian 
cysts may be either unilocular or multilocular, unilateral or bilateral. 
Sutton analyzed 60 cases in children under fifteen years of age, 
in which he found 23 dermoid, 16 sarcomata, and 16 simple cysts. 
Thornton has observed cases in which malignant deposits were found 
in the pelvis two or three years after the removal of dermoid cysts, 

sarcomata. 



572 AN AMERICAN TENT- BOOK OF GYNECOLOGY, 

Sutton arranges the group of malignant tumors in children — termed 
by some sarcomata, others carcinomata — under the term oophoromata, 
because they seem to arise from the tissue of the oophoron. Ovarian 
growths occur with greater frequency during the age of sexual activity, 
between the twentieth and fiftieth years. They are comparatively 
rare after sixty, and still more so before puberty. The unmarried 
seem to suffer with greater frequency from these growths. It is 
probable that the cessation of ovulation during pregnancy and lac- 
tation acts as a safeguard against their development, while menstrual 
congestion favors it. Several members of the same family have 
been affected. Each ovary seems to be attacked with equal fre- 
quency. It is estimated that the ordinary cystomata occur bilaterally 
in about 3 per cent., while the malignant, on the other hand, are 
found bilateral in about 75 per cent. Scanzoni has considered 
chlorosis during puberty as a main element in their development. 

Symptoms. — The tumor usually develops insidiously, and may 
attain considerable size before it is discovered, being then, pos- 
sibly, noticed by accident. The earliest symptoms are vesical 
tenesmus, constipation, pain in defecation, and the sensation of 
weight and pressure in the pelvis. As the tumor increases in size 
general nutrition becomes affected, due to the pressure upon the 
stomach and diaphragm. The patient becomes emaciated, grows 
weak, and suffers from violent abdominal pains, produced pos- 
sibly by a partial peritonitis. (Edema may occur in one or both 
legs and extend to the vulva or lower abdominal walls. The patient 
may have intercurrent febrile attacks, and death may occur from 
exhaustion, or where the tumor fills the pelvis it may produce 
incarceration similar to that resulting from retroversion of the 
pregnant uterus. 

Olshausen divides the subjective symptoms into four classes or 
groups : First, those produced by violent disease. This may be 
dysmenorrhea, but more frequently early and excessive hemorrhage. 
Excessive menstruation in bilateral tumors and tumors of the broad 
ligament is an early and obstinate symptom, due to the pressure 
upon the pelvic veins. Ergotin and other agents are useless in 
controlling the bleeding. This hemorrhage produces anemia. 
Sterility may result from the disease, partly from physiological 
and partly from mechanical causes. The fact must not be over- 
looked that conception has occurred with both ovaries occupied 
by large dermoid cysts. The presence of tumors may cause 



DISEASES OF THE OVARIES. 573 

pigmentation of the mammary areola and the linea alba, pain- 
ful sensation in the breasts, and even enlargement of these 
organs, with the secretion of milk. Second, symptoms which 
result from depression or weight of the tumor. These are con- 
stant after it has attained to some size. When it is situated in 
the pelvis it may produce tenesmus or strangury by pressure upon 
the neck of the bladder. A large tumor may produce upward 
traction on the bladder and urethra, and cause vesical disturbances, 
and even retention of urine. Defecation is impeded by pressure, 
and becomes painful if the tumor is sensitive. The patient suffers 
from vague, dragging pains, rupture of the rete Malpighii, and con- 
sequent formation of linea albicantes, dilatation of the veins, oedema 
of the abdominal walls, compression of the stomach and intestines, 
and difficult breathing by pressure against the diaphragm. This 
pressure necessarily adds an increase of danger to any inflam- 
matory trouble of the lungs. As a result of compression of the 
renal veins and ureters the patient may suffer from albuminuria 
or from suppression of urine by the compression of the ureters. The 
compression of the large abdominal veins causes marked oedema of 
the legs, though this is less frequent than in pregnancy. The tumor 
must be larger than the pregnant uterus to cause these symptoms. 
Third, symptoms of complicating disease. Of these the most fre- 
quent and important are those which arise from attacks of circum- 
scribed peritonitis. These symptoms are usually found in large 
tumors where they extend above the umbilicus. Loss of a portion 
of the superficial epithelium of the tumor necessarily results in its 
adhesion to adjacent parts. The greater the pressure of the tumor 
against neighboring organs, the more readily will the friction pro- 
duce adhesions. This is more likely to occur in the anterior surface 
of the tumor, producing adhesions between the tumor and anterior 
parietes. Next in frequency are omental adhesions, and then follow 
adhesions to the intestine, bladder, uterus, spleen, stomach, liver, and 
floor of the pelvis. These produce attacks of pain, lasting for days 
or weeks, with tenderness of the parts affected. Other complicating 
symptoms are pressure upon the intestines, producing intestinal 
irritation or obstruction ; intestinal occlusion from pressure upon 
the rectum, or occasionally, after puncture, from twisting of the 
intestines where they have been adherent. Fourth, symptoms on 
the part of the general condition of the patient. The general 
health of the patient usually remains good until the digestion is 



574 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

impaired by pressure upon the stomach. Then marasmus occurs, 
appetite is lost, the tongue becomes dry, there is persistent vomiting, 
and the features become sunken ; the expression of the face with the 
enormously distended abdomen presents symptoms which usually 
indicate the presence of the disease. 

Before taking up the study of the objective symptoms or physical 
signs of ovarian cysts we will enter upon the consideration of com- 
plications arising from changes in the cyst itself. These are — first, 
hemorrhages ; second, suppuration and gangrene of the cyst ; third, 
adhesions ; fourth, torsion of the pedicle ; fifth, rupture ; sixth, 
metastatic deposits. 

Hemorrhage into the cyst occurs from a variety of causes. It 
may take place in papillomatous cysts if the superficial vessels are 
greatly distended, or from the cyst-wall where the veins have rup- 
tured by dilatation. The most frequent cause is from torsion of the 
pedicle. Moderate torsion interferes with the return of the blood 
through the veins, while the arterial circulation may still be main- 
tained. It may take place from puncture through injury to a large 
vessel in the cyst-wall. Hemorrhage usually occurs slowly and in 
small quantities, and consequently is of no prognostic significance. 
Where copious, as in acute torsion of the pedicle, or where large ves- 
sels are punctured, it may seriously threaten life and produce pro- 
found and dangerous collapse. 

Inflammation and suppuration of a tumor may be produced by a 
number of conditions. Thus they may result from infection through 
the intestinal canal, urinary bladder, Fallopian tube, or the admis- 
sion of air in tapping. This may affect small as well as large cysts. 
Dermoids are especially prone to suppuration. The most common 
avenue of infection is through the Fallopian tube. Adhesions 
generally take place in the immediate neighborhood of its ostium, 
affording opportunity for inflammation to extend over the cyst, 
thus causing adhesions to the omentum, intestines, and parietal 
peritoneum. The intestines are sometimes the source of infection 
through adhesions of the small intestine or the rectum to the cyst- 
wall. As the adherent piece of intestine becomes compressed by the 
tumor, its wall becomes thinned, allowing the diffusion of intestinal 
gases. It may become so thin as to permit the gas to pass directly 
into the cavity of the cyst, causing putrefaction and converting it 
into a huge abscess; in some cases the inflammation has originated 
in an appendicitis. It was formerly supposed to be due invariably 



DISEASES OF THE OVARIES. 575 

to the accidental admission of air through tapping, but, as we have 
seen, it may occur independently of that cause. In acute cases, 
where inflammation results in early adhesions to the surrounding 
structures and viscera, marked symptoms arise, and unless the pus 
finds exit the patient dies. When exit is afforded, the patient may 
be worn out by the prolonged discharge. 

Symptoms are pain, tenderness over the region of the tumor, 
rapid and feeble pulse, great emaciation and exhaustion, with a tem- 
perature of 102° in the morning, 103-106° in the evening, or where 
the patients have become greatly exhausted the temperature may 
fall as low as 95°, especially when the pus is in considerable quan- 
tity. The urine may be found to contain albumen, and the cyst, 
through its communication with the intestine, may contain gas, pro- 
ducing a tympanitic note. Suppurating dermoids are not of infre- 
quent occurrence, often cause extensive adhesions, and burst into 
the peritoneum, rectum, bladder, vagina, or even through the 
abdominal wall. Communication of such a tumor with the blad- 
der excites profound distress. Portions of bone, teeth, locks of 
hair, or sloughs become packed in the urethra, and cause retention 
of urine and the occurrence of cystitis. Fragments remaining in 
the bladder are covered with phosphatic deposits and form a nucleus 
for the formation of calculi. 

Adhesions, when extensive, are always a source of additional 
anxiety. When they have existed for some time between the intes- 
tines, colon, and cyst- wall, forming broad, fibrous bands of close 
adhesions, the task of removal is an exceedingly tedious, and occa- 
sionally an impossible one. The adhesions result from inflamma- 
tion of the surface of the peritoneum, the exudation from which is 
slowly converted into fibrous tissue. If the parts remain in con- 
tact during the formation of the adhesions, what is known as a ses- 
sile adhesion is produced. If movement is kept up, the bands of 
adhesions are elongated, forming broad or narrow bands. The cyst 
may present a shaggy appearance from extensive adhesions. The 
older adhesions contain blood-vessels, which are of large size when 
the intestine or omentum is involved. The vessels thus formed are 
frequently so large that when a pedicle has been destroyed by tor- 
sion the tumor is still nourished by its new relation. The most 
dangerous adhesions are those in the pelvis, on account of their 
intimate relation with the iliac arteries and veins, and it is in 
many cases exceedingly difficult, if not impossible, to determine 



.376 AN AMERICAN TEXT-BOOK OE GYNECOLOGY. 

their presence until operation is resorted to. In separating pel- 
vic adhesions in a patient sixty-three years old, some years ago, 
using but very slight force, a large vein was torn open, and the 
patient lost so much blood before the hemorrhage could be arrested 
that she died a few hours later from shock. 

Axial rotation, or torsion of the pedicle, occurs in probably 10 
per cent, of the cases. It has been attributed to a variety of causes, 
as the alternate distension and evacuation of the bladder, passage 
of feces through the rectum, sudden movements, unusual exercise, 
the occurrence of pregnancy, delivery of the patient, and so on. It 
is more likely to occur in double ovarian tumor. It is possibly also 
induced by changes of position of the patient. The rotation varies 
from half a circle to as many as ten or twelve complete twists. The 
rotation takes place from right to left or left to right with about 
equal frequency, dependent, possibly, upon the side on which the 
tumor is situated. The tendency is to rotate toward the median 
line rather than from it. The effect on the circulation depends 
upon the amount of torsion as well as upon the thickness of the 
pedicle. A long, thin pedicle is the most frequently twisted. The 
veins are the first to suffer from the twisting, causing acute enlarge- 
ment of the cyst from extravasation of blood into its cavity. The 
veins may rupture and hemorrhage take place into the cavity of 
the cyst — hemorrhage so profuse as to produce acute anemia and 
even death. On opening the abdomen of such a patient, the cyst 
will be found dark-colored, more particularly near the pedicle. 
The fluid in the cavity may be chocolate or dark- red in color. 
The most frequent effect of torsion is thrombosis of the vessels, 
extravasation of blood, and necrosis. Necrosis is followed bv 
decomposition and putrefaction of the dead tissues. 

Torsion may be acute or chronic. In the latter the changes are 
slow. Acute torsion is generally seen in small tumors. The larger 
the tumor, the more profound is the constitutional effect. Symptoms 
of acute rotation are frequently so marked as to leave no question 
as to the condition. When the patient complains of sudden and vio- 
lent pain in the abdomen, vomiting, and the presence of acute swell- 
ing, one should suspect its occurrence. This is still more probable 
if the woman be pregnant. The rupture of the gravid Fallopian 
tube may induce symptoms which would be mistaken for torsion. 
The indications for prompt relief, however, are the same in each 
case. The symptoms in the chronic variety are not so marked. 



DISEASES OF THE OVARIES. 577 

The j)atients complain of a dull, sudden abdominal pain, and still 
maintain good health, with a tumor, however, which more rapidly 
increases in size. In these cases the prognosis is good if the adhe- 
sions are few or slight. 

Rupture of the Cyst. — Rupture of the cyst may be sudden, as the 
result of a fall, blow, or injury, or gradual from change in the cyst- 
wall. In the latter the cyst becomes thinner, more particularly in the 
papillary proliferating cystomata. In such growths, as they increase 
in size, the accumulation presses upon their walls, which become 
thinned, until they give way at some point or until the papillary 
growths project through the thinned walls. Rupture of the cyst 
may take place into adherent viscera, but more generally occurs 
into the peritoneal cavity. The result of such a lesion is depend- 
ent somewhat upon the quantity and quality of the fluid contained. 
In the unilocular cysts the fluid is most innocuous, and may fre- 
quently produce no abnormal symptoms other than an increased 
diuresis. The patient probably passes several gallons of water in 
twenty-four hours. The abdomen, so prominent from the tumor, 
becomes flattened, flabby, and possibly the remnant of the cyst may 
be recognized upon palpation. Rarely the cyst-wall may shrivel 
and a radical cure be effected. In the multilocular cysts, and par- 
ticularly the dermoids, rupture into the peritoneal cavity may be fol- 
lowed by infection, a rapidly developing grave peritonitis, and 
finally death. This termination is quite probable, not only in 
dermoids, but in those containing colloid material, or particularly 
where pus is present in the cyst. In dermoids the decomposing 
fat is eminently productive of inflammation. Death may be very 
rapid as a result of shock or the absorption of the deleterious mate- 
rial. In papillary cystomata rupture results in the infection of the 
peritoneal cavity and the formation of growths upon its surface, in 
some cases studding the entire peritoneum. Rupture is determined 
by disappearance of the tumor, diminution in its size, demonstration 
of free fluid in the abdomen, peritonitis, collapse, and diaphoresis 
or diuresis. Rupture into the peritoneal cavity may be mistaken 
for torsion ; when into the intestines, it is recognized by the evac- 
uation of colloid masses or chocolate-colored fluid ; where the open- 
ing is high up, violent watery diarrhea may occur ; when into the 
bladder, by vesical tenesmus and dysuria; or where dermoid, it is 
recognized by the peculiar contents of the cyst. External rupture 
is usually determined without difficulty. When pus or ichorous 



578 AN A3IEBICAN TEXT-BOOK OF GYNECOLOGY. 

material alone are discharged, it is sometimes difficult to determine 
whether it proceeds from a cyst or an abscess in the walls. 

Metastasis occurs in cancer of the ovary extending to the perito- 
neum, causing ascites, or secondary nodules may be found in remote 
organs, as the liver, spleen, and, rarely, the kidney. In papillary 
growths the peritoneum becomes infected, and through the peristal- 
tic action may infect the entire abdomen. So extensive is the infec- 
tion, and so prone to occur after the removal of these tumors, that 
it has been sometimes questioned whether papillary tumors did not 
belong to the malignant class. Their structure, formation, and the 
fact that they are not always absolutely fatal renders this improb- 
able. The dermoid element has also been found implanted in the 
peritoneal cavity. Small tufts, covered with hair, have been noticed 
growing from the surface of the peritoneum of the intestine. A 
similar covering with colloid material has been found in multiloc- 
ular cysts. 

In a case operated upon by the writer some years ago the entire 
peritoneal cavity was studded with a thick colloid material which 
could not entirely be scraped off. 

Other complications of ovarian cyst are — 

1. Ascites. — A small amount of ascitic fluid may be present with 
many cysts, but a large quantity is rare so long as the tumor retains 
its normal condition. Changes in its structure, especially if of 
malignant character, are prone to result in an increase of free peri- 
toneal fluid. In malignant disease the fluid becomes darker, like 
prune-juice. 

Large ascitic accumulations result from rupture of colloid or par- 
ticularly of papillary cysts. Solid growths are generally attended 
with ascites. The presence of fluid in the peritoneal cavity is by 
no means an indication of malignancy, as it occurs in fibromata 
as well as in sarcomata and carcinomata. In the former it is prob- 
ably due in part to the irritation of the peritoneal epithelium and in 
part to pressure upon the vessels. 

2. Intestinal obstruction or strangulation from pressure of the cyst 
or adhesions to its surface, or torsion or volvulus from such adhe- 
sions takes place when the tumor has been reduced by puncture. The 
intestine may become occluded by extension of malignant disease. 

Course, Duration, and Termination. — The rapidity of the 
growth of an ovarian tumor depends somewhat upon its character. 
Those of slow growth are usually cysts of the broad ligament, 



DISEASES OE THE OVARIES. 579 

fibromatous tumors, and the fibro-myomata of the ovary. Prolifer- 
ating cysts, whether glandular or papillary, grow more rapidly. 
The latter grow so rapidly that considerable increase in size may 
be noticed in ten days. The intra-ligamentary cysts of papillary 
origin are generally of slow growth. At the end of years they 
may not be larger than a child's head. Such patients suffer from 
profuse menstruation, due to the pressure upon the veins obstruct- 
ing the return circulation. In the later stages ascites is developed, 
which rapidly returns after tapping. It is difficult to determine 
the duration of the disease where undisturbed. In 60 to 70 per 
cent, at least of the proliferating cystomata the patient dies within 
three years after the advent of the first symptoms, and another 10 per 
-cent, die within four years. The slow-growing papillary cystomata 
generally cause the death of the patient from marasmus, but the 
average duration of the disease is longer than in the proliferating 
variety. Such a patient has been punctured one hundred and five 
times in seven years, with the removal of twenty-five to forty 
pounds of fluid at each operation. The proliferating cysts may 
remain unchanged even for years. Patients suffering with ovarian 
cysts may heal spontaneously or pass into a condition which is 
equivalent to recovery. Spontaneous recovery generally occurs 
from rupture of the cysts. This favorable result occurs more par- 
ticularly in simple cysts, but rarely, if at all, in the proliferating. 

Torsion of the pedicle, or axial rotation, may bring about 
recovery in colloid tumors. Such a termination, however, is rare, 
and the recovery is not absolute, as there usually can be found a 
mass in the former position of the tumor. Spontaneous recovery, 
indeed, is rare, even in unilocular cysts, and in the proliferating 
cystomata is never looked for. Unless such patients are subjected 
promptly to surgical treatment, death occurs in the majority of 
cases from exhaustion, as a result of anorexia, impaired digestion, 
sleeplessness, and interfered respiration and circulation. Patients 
may suffer from bed-sores or intercurrent disease, which may 
rapidly prove fatal. Death is occasioned in other cases from peri- 
tonitis after torsion of the pedicle, rupture, or metastasis upon the 
peritoneum. Other fatal conditions may be intestinal occlusion 
and embolism of the pulmonary artery. The presence of ascites 
in considerable quantity is generally an unfavorable omen. Another 
cause of fatal result may be suppuration from puncture. This re- 
sult was formerly very frequent. The presence of ascites must be 



580 AN AMERICAN TEXT-BOOK OE GYNECOLOGY. 

considered an unfavorable symptom when it is associated with papil- 
lary growths or rupture of a glandular tumor. A tumor which has 
not been long in existence and which undergoes sudden develop- 
ment, attended with rapid emaciation and cachexia, multiple adhe- 
sions, especially in the pelvis, and oedema of the lower limbs and 
the abdominal walls, with peritonitic complication, should indicate 
a malignant onset. In such cases the outlook for a successful ope- 
ration is bad, although operation should be done wherever there is 
the least chance for success. 

The physical signs of the patient are determined by inspection, 
palpation, percussion, and auscultation. In the examination of the 
patient she should be placed upon a bed or couch, the limbs drawn 
up, clothing loosened, all constricting bands removed, so that the 
abdomen can be thoroughly and completely exposed. It is well that 
the patient should have been previously directed to have the bowel 
and bladder emptied. After covering the lower extremities with a 
sheet, and bringing it over the lower part of the abdomen so as to 
avoid exposure of the genitalia, the abdomen is bared. The first 
general procedure in examination is that of inspection. By inspec- 
tion we are enabled to determine the size of the growth, the height 
to which it rises from the abdomen, its position, whether symmetrical 
or one-sided, the smoothness of its outline, whether spherical or 
larger from side to side, the appearance of the skin, presenting the 
linea albicantes, darkened line down the centre — the linea nigra — 
discolorations of the skin indicating the application of counter-irri- 
tants and the presence of pre-existing inflammatory troubles. An 
irregular nodular appearance of the tumor would indicate that if 
cystic it consisted of a number of cysts causing irregularity of the 
surface. The dark line is generally considered a symptom of preg- 
nancy, but when it occurs it is permanent in duration, so that it is 
only in the first pregnancy that it is of value. It should not be 
forgotten, however, that this increase of the local pigment occurs in 
women who suffer from ovarian cyst or uterine fibroids ; the pres- 
ence of linea albicantes has no significance as regards the question 
of pregnancy. They arise from any distension of the abdomen 
sufficient to cause rupture of the skin, and hence are found not 
only in pregnancy, but in ovarian cyst, ascites, and other conditions 
which are likely to cause abdominal enlargement, and may be 
entirely absent in women who have borne children. 

Palpation is practised by placing the hand over the abdomen, in 



DISEASES OF THE OVARIES. 581 

cold weather the hands having previously been warmed. The 
abdominal cavity is carefully explored, the condition of the various 
organs investigated, and any enlargement of the abdomen, presence 
of a cyst or tumor, can generally be recognized readily. Palpation 
is practised by placing the hands now upon opposite sides of the 
abdomen and then close together, going over one portion after 
another, so determining the size, consistency, resistance, and regu- 
larity of the growths, the presence of outgrowths or nodules, and 
the sensation of crepitation or of friction. Placing the hand upon 
one side and striking gently with the other will elicit fluctuation, 
particularly when we are dealing with a large unilocular cyst. In 
multilocular growths the fluctuation wave would be shorter or may 
be entirely absent. 

Percussion is of special value in determining the outline or ex- 
tent of growths, their relation to the abdominal viscera, and their 
determination from other forms of abdominal distension. It affords 
an absolute means of differentiation of growths from distensions of 
the abdomen by free fluid or accumulations of gas. 

Auscultation gives but slight information. It is of service 
in differential diagnosis, more particularly in its negative results. 

Diagnosis. — The diagnosis of ovarian tumors may be divided 
into two divisions : first, the determination of such growths when 
small and situated in the pelvis ; second, when large, filling the 
greater part of, or the entire, abdominal cavity. 

The physical signs vary according to the size and position. In 
the former stage the tumor is entirely within the pelvis and its posi- 
tion varies. It may retain the normal situation, and as it increases 
in size may encroach upon the general abdominal cavity. Tumors 
when as large as a hen's egg, however, generally fall downward and 
backward into Douglas's pouch immediately behind the uterus. In 
rare cases they may be found in front or to one side. The ovary, but 
slightly enlarged, may retain its normal position. Its relation to 
the corresponding side of the uterus affords but little difficulty in 
determining its character by conjoined manipulation. Where its 
growth has been associated with peritonitic inflammation, it may be 
more difficult to determine its true character. Small tumors are 
usually firm to the feel, for the reason that they are too small to 
produce an elastic consistency. In a large tumor situated behind 
the uterus the diagnosis is determined by the circumscribed cha- 
racter of the growth. Elasticity is a valuable sign, which is gen- 



582 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

erally absent in proliferating cystomata, and even in single cysts, 
and particularly dermoids, which afford a solid sensation to the 
touch. If we are unable to determine or separate the tumor from 
the uterus, and consequently to determine its pedunculation, this 
can be ascertained by Hegar's method, which consists in placing 
the patient upon her back, seizing the uterus by a pair of volsella 
forceps, and strongly dragging it down ; at the same time we en- 
deavor to feel the lateral borders of the uterus as far as the fundus 
with one or two fingers in the rectum, or we push the uterus down- 
ward and backward by means of the outer exploring hand, and 
thus outline its relations. When the tumor is not too large it can 
generally be outlined with the finger in the rectum and the hand 
over the abdomen. The greatest difficulty is experienced in those 
cases in which the tumor is adherent in the pelvis and surrounded 
by exudation or is incarcerated. Tumors which are situated en- 
tirely within the broad ligament, and formed unilaterally or bilat- 
eral] y or in close apposition to the uterus, are less spherical and cir- 
cumscribed, and less movable from the start. Small growths must 
be diagnosed from fibroids and tumors caused by disease of the 
tubes, particularly hydro-, pyo-, and hematosalpinx. The more 
acute history, marked tenderness, evidence of inflammatory exu- 
dation, thickening and matting together of the pelvic tissues, and 
increased pain, would eliminate pyosalpinx. In hydrosalpinx the 
tumor may be movable, present a sensation of elasticity or fluctua- 
tion, but it is oblong or gourd-shaped rather than spherical. It is 
closely attached to the uterus and presents a history of previous in- 
flammation. Hematosalpinx is at first soft, and then becomes hard 
and dense from coagulation of the blood. It is situated to one side 
of the pelvis rather than posterior to the uterus. 

Large or Abdominal Cysts. — In a woman suffering from a 
laro-e ovarian cyst the abdomen will be found distended more 
particularly at its lower part, quite prominent, and rising ab- 
ruptly from the pubes. As the patient lies upon her back 
with the abdomen exposed, it will be seen to be sharply and 
definitely outlined, and generally symmetrically developed ; if 
any difference, a little more prominent on the right side. Palpa- 
tion may determine its outline, extent, and size. If there is a 
large single cyst, the surface will be smooth and regular, while in 
multilocular cysts it may present projections and irregularities. If 
made up of a number of small cysts, it will present a much more 



DISEASES OF THE OVARIES. 583 

marked resistance, although there is still a sensation of elasticity. 
The tumor may be moved from side to side or pushed upward and 
downward. Percussion discloses dullness over the entire surface 
of the tumor, with resonance above and possibly resonance in the 
flank upon one side. The resonance in this region is supposed to 
indicate that the tumor has developed from the opposite side or 
ovary, and as it increased in size has pushed the intestines upward 
and to the unaffected side. We cannot, however, with certainty 
determine in this way the ovary from which the tumor has arisen, 
as when the growth has increased in size it is likely to become 
prolapsed into Douglas's pouch and develop from there ; conse- 
quently this does not afford a positive indication as to the source 
of origin. 

Considering the conditions with which ovarian cyst may be con- 
founded, it is well to begin with pregnancy, from its greater frequency 
and importance. It may seem unreasonable that pregnancy should 
be mistaken for an ovarian cyst; but there are a number of cases 
upon record in which the abdomen has been opened to find the 
distention caused by a pregnant uterus. In order to arrive at a 
correct diagnosis we need to carefully analyze the symptoms of the 
two conditions. In this we consider the history of the case. In 
pregnancy the enlargement of the abdomen is more rapid, and is 
generally attended by suppression of the menstruation, the sym- 
pathetic symptoms, nausea, vomiting, disturbed appetite, and a 
healthy appearance of the individual. Suppression of menstrua- 
tion is not a constant symptom of pregnancy, as there are women 
who continue to menstruate during the entire period of pregnancy. 
It may be associated with ovarian cyst, particularly where both 
ovaries are completely degenerated. Error is most likely to occur, 
in early pregnancy, in the unmarried. In these cases the physician 
should carefully avoid announcing a diagnosis until a careful exam- 
ination has been made, and even then should not be too hasty. If 
there is any doubt, he should defer expressing an opinion, and have 
the patient undergo an examination a few weeks later. The changes 
which occur will generally be sufficient to enable him to express a 
definite opinion. In pregnancy there is generally an absence of 
fluctuation. The same symptom may be absent in ovarian cyst with 
thick viscid contents, or in the areolar or glandular varieties made 
up of a large number of small cysts. Later, fetal movements and 
parts of the fetus may be distinguished, and the fetal heart-sounds 



584 AN AMEBIC AN TEXT-BOOK OF GYNECOLOGY. 

recognized. The latter symptom is one which is pathognomonic of 
pregnancy. Heart-sounds, however, are not always heard, owing to 
the position of the fetus and the large quantity of fluid or possible 
fetal death. Conjoined examination through the vagina or rectum 
should be a part of the procedure. By it we are enabled to deter- 
mine the association of the abdominal distension with the increased 
size of the uterus. Gestation in one horn of a bicornate uterus may 
render diagnosis difficult. Careful examination by the vagina and 
rectum will show the association of the enlargement with the uterus, 
the other cornu possibly remaining small. Where there is the least 
suspicion of pregnancy the introduction of the uterine sound should 
absolutely be avoided. 

Hy dr amnios. — Cases in which the liquor amnii exceeds two 
quarts have been mistaken for ovarian tumor. Large accumulations 
within the walls of the uterus give rise to fluctuation, the abdominal 
walls will be greatly distended, glistening, and the patient will suffer 
from all the discomfort arising from a marked abdominal distension 
from ascites or ovarian cyst. This condition generally comes on 
suddenly, and takes place about the sixth or seventh month of preg- 
nancy, which prior to its occurrence has run a normal course. On 
examination the uterus will be found distended, possibly the cervix 
obliterated, the os open, covered with a dense membrane, and by 
manipulation we may be able to distinguish the symptom of bal- 
lottement ; rupture of the membrane results in the discharge of a 
quantity of water and the emptying of the uterus. The existence 
of ovarian cyst of one or both ovaries does not necessarily indicate 
the non-existence of pregnancy, as so long as any ovarian stroma 
remains unaffected, ovulation and conception may occur. The 
increased quantity of blood directed to the pelvis during the prog- 
ress of pregnancy may increase the rapidity of development of 
an ovarian cyst. The enlargement of the abdomen may be so 
marked as to indicate the necessity for interference with the pro- 
cess in order to prolong the patient's life. Careful examination 
will disclose the enlarged uterus either in front of or behind the 
ovarian cyst. In some cases the ovarian cyst may be situated in the 
pelvis and obstruct the vagina, rendering it difficult to reach the 
cervix. In the later months of pregnancy such cysts may be tapped, 
permitting the completion of gestation, or, if discovered early, 
ovariotomy may be performed. The occurrence of pregnancy does 
not seem to influence the mortality of the operation. 



DISEASES OF THE OVARIES. 585 

Morbid collections within the uterus may be physo-, hydro^, or 
liematometra. Physometra is a collection of gases within the uterus, 
the result of decomposition, and is a very rare condition. Hydrome- 
tra is a collection of water in the organ which is more likely to take 
place in women of advanced age, due to the retention of the secretions 
from obliteration of the canal. Hematometra may result from occlu- 
sionof the cervix or vagina, with retention of menstrual discharges. 
It is more likely to occur near puberty. Examination by vagina 
or rectum is usually sufficient to demonstrate the cause. Other 
growths within the uterus which have led to difficulty in diagnosis 
are myomata or fibro-myomata. These growths are rare before the 
twenty-fifth year ; indeed, not common before the thirtieth. They 
are more likely to be confounded with ovarian tumors on account 
of the very great size to which they attain, filling up the entire 
abdominal cavity and presenting a tumor larger than the pregnant 
uterus at full term. These growths are usually of slow develop- 
ment and irregular in outline. They are firm and without fluc- 
tuation. They may cause no disturbance of the menstrual func- 
tion, as in the subperitoneal fibroids or marked monorrhagia as 
in the submucous. Vaginal examination discloses the close, asso- 
ciation of the tumor with the uterus. Generally movement 
of the tumor will cause movement of the cervix. Where the 
tumor is connected with the uterus by a long pedicle, it may be 
more difficult to determine its character. This may be accomplished 
by having the tumor, through the abdominal walls, drawn up by 
an assistant, while the cervix is drawn down by a volsellum in the 
hand of the examiner, who introduces the finger of the other hand 
into the rectum, and thus definitely determines the association of 
the mass with the uterus. If it can entirely be separated from that 
organ, it is evident the growth is ovarian. Auscultation usually 
discloses a blowing sound due to the coursing of blood through the 
large uterine sinuses — a condition which is absent in ovarian cysts. 
The conditions which are most difficult to determine are those in 
which a fibroid with long pedicle is oedematous, giving a sensation 
of elasticity, or an ovarian cyst with thick, viscid contents, or those 
cases of fibroid growth which have undergone cystic degeneration. 
The methods we have already mentioned of determining whether 
the growth is a part of the uterus may be exercised. Cases of doubt 
may be determined only during the progress of the operation. 

Ascites. — There is generally little difficulty in arriving at a cor- 



586 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

rect diagnosis in cases of uncomplicated ovarian cyst. Unilocular 
ovarian cysts probably more frequently than any others are con- 
founded with ascites. It may be avoided by keeping in mind that in 
ascites, if the patient lies upon her back, the abdomen is likely to 
be flattened, broader from side to side — that there is less resistance, 
and upon palpation the abdominal wall can be depressed to a greater 
degree, displacing the free fluid. Upon percussion in ascites there 
is a zone of resonance at the summit of the distension, due to the 
intestines filled with gas floating to the surface, while there is dull- 
ness in the flank and over the sides. In ovarian cyst there is dull- 
ness over the surface of the distension, resonance above it and over 
one flank. In ascites the level of the fluid changes with the change 
of position, consequently the resonance changes ; in ovarian cyst it 
is unchanged. Very marked abdominal distension may afford an 
element of uncertainty in the fact that the distension is so great 
that the mesentery is too short to permit the intestines to come in 
contact with the abdominal surface. In such cases depressing the 
abdominal walls, thus displacing the intervening layer of fluid, may 
afford resonance, while superficial percussion is dull. Entrance of 
gas from an intestinal communication or decomposition of the cyst- 
contents may render an ovarian cyst resonant. In these cases we 
will have to depend upon the resistance of the cyst to determine its 
presence. In cases of ascites, also, the history will be of advantage, 
as affording information of renal, cardiac, and hepatic disease. In 
ascites the wave of fluctuation may be followed around in the flank 
where it would be absent in a cyst. In inflammatory ascites or 
ascites from tubercular peritonitis the diagnosis may be difficult, and 
only determined after incision. Ascites may complicate an ovarian 
cyst ; thus by depression a layer of fluid may be displaced, bring- 
ing the hand in contact with the tumor within. The amount of 
resistance will determine whether the tumor is solid or cystic. The 
occurrence of ascites complicating a cyst may generally -be consid- 
ered as an indication of malignancy or some degenerative process. 
The more marked the ascites, the greater the probability of malig- 
nancy. The uterus will be found freely movable in ascites, while 
in ovarian cysts it will be displaced either downward and backward 
or upward and forward. In ascites from ruptured papillary cysts 
the uterus presents on either side a dense thickened mass which 
should cause a suspicion of its true character. 

Phantom Tumor. — Phantom tumor is a condition in which there 



DISEASES OF THE OVARIES. 587 

is an apparent tumor due to distention by gas. This may in some 
cases attain to considerable size, and when associated with the illusion 
of supposed pregnancy is known as pseudo-cyesis. It is more likely 
to occur in nervous sterile women. The form just spoken of occurs 
in cases of illicit intercourse in young individuals in whom there is 
a fear of pregnancy, or in older women in whom there is a morbid 
desire to have children. Such patients will experience the fetal move- 
ments and all the ordinary sensations of pregnancy. It is likely 
to occur at or near the climacteric, and is generally associated with 
a large increase of adipose tissue. Percussion over the abdomen is 
sufficient to disclose the fact that the apparent tumor is filled with 
gas. Palpation will generally elicit the absence of any tumor, or, 
if the swelling or distension remains permanent under pressure, it 
may. be entirely removed by placing the patient under the influence 
of an anesthetic. 

Uterine Myomata complicating Ovarian Cyst. — The presence 
of a cyst of the ovary and a fibroid tumor of the uterus in 
the same patient is not infrequent. Where the ovarian cyst is 
large and situated in front of the uterine tumor, the diagnosis 
may be difficult, and only determined after puncture of the cyst or 
abdominal section. The author recently made a diagnosis of this 
condition in a patient with the following history : A woman set. 33 
years, married, had been suffering with abdominal enlargement for 
nearly a year, which for the last four months had increased more 
rapidly. She had been suffering from irregular hemorrhage ; was 
pale and emaciated; she complained of severe pain over the abdo- 
men, increased by exertion. The abdomen was distended about the 
size of a six months' pregnancy ; upon the right side, a little below 
the level of the umbilicus, was a hard, firm growth, apparently 
closely associated with a tumor upon the left side which extended 
above the umbilicus. The left tumor was more elastic and apparently 
contained fluid. Moving the mass upon the right caused the cervix 
to move, while movement of the left tumor apparently had no influ- 
ence upon it. The diagnosis was, right side, myoma; left side, 
probably ovarian cyst made up of small cysts. Upon preparation 
for operation she was found to present a softened, dilated cervix, a 
bloody discharge, and within the uterus a fetus which gave evidence 
of having been two weeks dead. 

Obesity. — A large pendulous abdomen from accumulation of fat 
within its walls or fat in the omentum may be mistaken for an 



588 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



ovarian cyst. The history of development, the general distribution 
of adipose over other parts of the body, while with ovarian cysts 
there is loss of adipose or emaciation, aids in the diagnosis. The 
thickness of the abdominal walls may be estimated by pinching up 
a fold of the skin and subcutaneous tissue. 

Ventral Hernia. — In two cases the author has been called to 
see patients suffering from supposed ovarian cysts, when the con- 
dition was due to separation of the recti muscles and protrusion 
of the intestines covered only by skin and peritoneum. Palpa- 
tion of the intestinal coils and resonant percussion should have ex- 
cluded the diagnosis of a cyst. 

Desmoid Tumors. — These tumors originate in the fascia or deeper 



Fig. 3 




Fatty Abdominal Wall, Simulating Ovarian Cyst. 



layers of the muscles. They are firm and resisting, are movable 
within the abdominal walls, above the surface of which they project 
to a marked degree. Vaginal or rectal examination aids in exclud- 
ing them from a pelvic origin. 



DISEASES OF THE OVARIES. 589 

Tympanitis. — Abdominal distension, as in phantom tumors, 
whether local or general, is characterized by resonance. The latter 
is associated with symptoms of inflammation ; the former occurs in 
nervous, hysterical individuals. 

Fecal Tumors. — An accumulation of feces is sometimes called a 
fecal tumor. It generally takes place in the colon. If it occurs in 
the transverse colon, that organ may be displaced downward by its 
weight, and rest over the lower part of the abdomen. Such accumu- 
lations are sometimes quite extensive. They are distinguished, how- 
ever, by the length of the tumor, the peculiar sensation to the touch, 
the fact that it retains the imprint of the finger, and that it is en- 
tirely removed by free purgation and copious enemata. 

Distended Bladder. — An over-distended bladder forms a tumor 
in the lower part of the abdomen, wmich fluctuates, is sensitive to 
pressure, and may be mistaken for a cyst. The precaution should 
always be taken to empty the bladder as a preliminary step to ex- 
amination. It will of course thus be eliminated. In cases of preg- 
nancy or fibroid tumor impacted in the pelvis, or even in impacted 
ovarian cysts, we may have retention resulting, and difficulty in 
the introduction of a catheter. In such cases it may be necessary 
to use a soft male catheter. 

Cystic tumors, which may be mistaken for those of the ovary, are 
hydatid cysts of the liver and spleen, and cysts of the omentum, 
mesentery, pancreas, and kidney. Instead of cysts of the kidney, 
we may have the entire structure of the organ dilated, giving rise 
to a hydro- or a pyo-nephrosis. Hepatic cysts or dilatations of the 
gall-bladder are only mistaken for ovarian cysts when they are very 
large, filling up the abdominal cavity or by their weight dragging 
down toward the pelvis. When small they are found situated in 
the upper part of the abdomen to the right side. The diagnosis is 
usually determined by the percussion resonance being situated to 
the opposite side and the lower part of the abdomen, while there 
is dullness above. On vaginal examination the position of the 
uterus will be disclosed ; possibly also the enlarged ovaries on 
either side of it may be recognized. In hydatid cyst crepitation 
elicited by placing the hand over the cyst, and making pressure, 
will aid in determining its character. This is still further con- 
firmed by finding upon microscopical examination of some of the 
fluid withdrawn for that purpose, booklets and spurs of the echino- 
cocci. Tumors of the spleen are situated on the left side of the 



590 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

abdomen, and extend downward toward the pelvis, not infrequently 
extending across the abdomen. Mesenteric and omental cysts attain 
a considerable size, and often present great difficulties in diagnosis. 
Manipulation may, however, disclose the absence of attachment to 
the pelvic organs, and in this way afford a suspicion of their true 
character. The mesenteric cysts usually develop behind the peri- 
toneum, and are consequently retro-peritoneal cysts. They may 
be situated to one side of the abdomen or in the median line, and 
usually do not dip down into the pelvis. Fluctuation is indis- 
tinct, and may be associated with resonance from the overlying 
intestine. Renal cysts in their origin develop from one side of the 
abdomen, are usually more or less fixed, and, increasing in size, may 
be pushed or displaced downward, in some cases occupying the 
anterior surface of the sacrum. An important aid in the diagnosis 
of these tumors is their mobility. Retro-peritoneal cysts some- 
times develop in the pelvis, filling it up and rising upward into the 
abdominal cavity. Such tumors will usually be found closely asso- 
ciated with the uterus and difficult to separate from it ; the uterus 
will be lifted up by them, the fundus felt in front of the tumor, 
above the symphysis ; there will be a displacement generally of the 
rectum more to the left side, or it may run over the anterior surface 
of the tumor. These tumors are more or less resisting, presenting 
a sensation of elasticity rather than of fluctuation. They are gen- 
erally rapid in growth and of a malignant character, more likely to 
be sarcomatous. 

Where our examination satisfies us that we have to deal with an 
ovarian cyst, it still becomes a question of considerable importance 
to determine its character, whether single, multilocular, or der- 
moid. Multilocular cysts are usually of more rapid growth. 
They present a sensation of greater resistance than the unilocu- 
lar, with a less distended wave of fluctuation. In the unilocular 
cyst the wave of fluctuation can be felt distinctly from one side 
of the abdomen to the other. In the multilocular, as the cyst is 
divided up into a number of smaller cysts, the wave of fluctua- 
tion must necessarily be shorter, and if the cysts are sufficiently 
small no fluctuation will be distinguished. These cases are some- 
times exceedingly difficult to determine from the oedematous fibroid, 
and it is only by careful manual examination, by which the associ- 
ation of the latter with the uterus is determined, that we are able to 






DISEASES OF THE OVARIES. 591 

arrive at a diagnosis, and in some cases only an abdominal incision 
will afford us a correct knowledge. 

A case came under observation a year ago in which to the right 
of the cervix was found a mass, somewhat hard and resisting, which 
was felt to be continuous with the cervix. Above this was a con- 
siderably larger mass, soft and elastic, and between this and what 
we had supposed to be the entire uterus was tissue into which the 
fingers could be pressed. This apparently indicated that the tumor 
had grown from the broad ligament and was closely associated with 
the uterus. The diagnosis was a probable intra-ligamentary ovarian 
cyst. Upon opening the abdomen the mass which we had sup- 
posed to be an ovarian cyst proved to be an cedematous fibroid. 
The mass to the right, which was firm, was a second fibroid in a 
more mature condition, and the soft line between them was the 
junction of the fibroid with the body of the uterus. 

Dermoids are distinguished by their slow growth, greater mobil- 
ity, sensation of resistance, and absence of fluctuation. 

Adhesions. — Adhesions may be expected where a tumor has 
attained a very great size ; under the pressure the tumor suffers a 
loss of the epithelial layer ; roughening of its surface follows, with 
a tendency to a slight peritonitis and the formation of adhesions. 
These are more likely to take place over the anterior surface of the 
tumor, and next in frequency between it and the omentum. The 
history of repeated attacks of peritonitis during the progress of the 
growth will almost certainly indicate extensive adhesions. They 
will occur also in inflammatory conditions of the cyst, whether 
resulting from torsion of its pedicle, from suppuration, or from 
gangrene. The mobility of the tumor or the ease with which the 
abdominal walls can be moved over it leads us to hope that adhe- 
sions are slight, though we cannot absolutely determine that it is free 
from them. 

Pedicle. — Enlargement of the ovary causes it to prolapse and 
drag upon its attachment to the broad ligament, and thus become 
more or less pedunculated. This elongation of its neck becomes 
increased when the tumor is large enough to rest in part upon the 
brim of the pelvis. The neck or attachment is known as the pedicle. 
It is composed in most cases of a part of the broad and ovarian liga- 
ments, and generally contains the Fallopian tube. The thickness 
and length of the pedicle can only be determined with certainty at 
the time of removal. Where the tumor is freely movable it is rea- 



592 AN AMERICAN TEXT-BOOK OE GYNECOLOGY. 

sonable to suppose that we have to deal with a long pedicle. Ele- 
vating the tumor with the external hand while a finger of the other 
is introduced into the vagina, or better into the rectum, 'the connec- 
tion of the growth to the uterus can be determined. 

Exploratory Puncture. — In obscure and complicated cases the 
diagnosis is so difficult that it has been deemed desirable to deter- 
mine the character of the tumor and its contents before deciding as 
to what operative procedure to adopt. To accomplish this, the 
removal and examination — chemical and microscopical — of a portion 
of the cyst-contents have been recommended. 

It should be remembered that the operation of aspiration of 
a cyst is not unattended with danger, as the intestines and 
bladder have been frequently punctured. There may be an escape 
of fluid into the peritoneal cavity or the entrance of air into the 
tumor, and the latter may be followed by gangrene or suppura- 
tion. A large vessel in the tumor-wall may be injured by the 
introduction of the aspirator, and an extensive hemorrhage result. 
In view of these dangers tapping is rarely justifiable. 

A proliferating cyst usually furnishes fluid of a thick, colloid 
character, with a specific gravity of 1015-1030, which contains 
paralbumen and cylindrical epithelial cells. In the papillary 
cysts there is an absence of paralbumen, while the microscope 
discloses white blood-corpuscles. The fluid from the Graafian 
follicles is not distinguishable from that obtained from parovarian 
cysts. Ascitic fluid is thin, light yellow or greenish-colored, deposits 
albumen on boiling, does not contain cylindrical epithelium, and 
has a specific gravity of 1008-1015. In the cysto-fibromata the fluid 
has a lemon-yellow color, with a specific gravity of 1020, coagulates 
rapidly without heat, and does not contain cylindrical epithelium. 
The fluid from echinococcus cysts is distinguished by the hooklets, 
and has a specific gravity of 1008-1010, without albumen. In 
hydronephrosis the fluid is thin, with a specific gravity of 1005- 
1018, varies in color, and contains urea, leucine, tyrosine, and 
kreatinine. Puncture in an ovarian cyst is always dangerous, and 
when performed for diagnosis in doubtful cases, as in echinococcus 
cysts, renal tumors, abscesses, or dermoids, it may be attended with 
the most serious consequences. The exploratory incision is a far less 
dangerous procedure. In cases in which it is impossible to arrive 
at a correct diagnosis, as in ascites from tubercular peritonitis or 
malignant disease of the ovary, tube, or omentum, or from papillary 



DISEASES OF THE OVARIES. 593 

cysts, the buttonhole incision, through which one finger can be 
introduced, is far the preferable procedure, and, while admitting 
opportunity for the determination of the condition by touch, affords 
a subsequent opportunity for drainage. 

Treatment. — As the fluid is contained within a closed sac which 
has its own secreting surface, the administration of remedies or the 
use of counter-irritants for the purpose of decreasing the accumu- 
lation by increased secretion and elimination is without reason. 
Electrolysis has been advocated, but when we consider the charac- 
ter of such growths and the danger of infection from many of them, 
it is too dangerous a plan to be considered. Surgical treatment con- 
sists of extirpation. Puncture is at best only a palliative measure, 
as the removal of the fluid is quickly followed by its re-accumula- 
tion, and is attended with great loss of albumen. The first puncture 
would necessarily be followed by others at shorter intervals, until 
the patient becomes exhausted by the severe drain. As has already 
been mentioned, it is attended with clanger from the direct loss of 
blood, as the opening of a vessel, presence of papillary cysts, and 
rupture of a thin-walled cyst and the spreading of its papillary 
contents to the peritoneal cavity, as well as from septic infection. 
The operation may be done in pregnancy in the later stages in 
preference to ovariotomy as a temporary expedient, where the cyst 
is situated in the pelvis and would interfere with the delivery of 
the patient. Under these conditions the puncture should be made 
through the vagina. 

This is an exceedingly dangerous procedure, however, as the 
vaginal canal is difficult to render thoroughly aseptic. Puncturing 
the cyst through the rectum is under all circumstances absolutely 
unjustifiable. 

Ovariotomy. — The only treatment that is applicable to all cases 
and is worthy of consideration is the extirpation of the tumor, or ova- 
riotomy. Success in the performance of this operation will depend 
very much upon the care with which the diagnosis has been made, 
the knowledge of the operator concerning the condition of the 
patient, the dexterity with which the operation is performed, or the 
readiness in meeting complications, and the judicious treatment of 
patients subsequent to its performance. 

Operation. — In considering the conduct of the operation we pre- 
fer to divide it into different steps or stages and describe the method 
of procedure in each. By so doing we feel that we can impress 



594 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

upon the would-be operator a graphic outline of the various acci- 
dents which may occur and the subterfuges to which he may be 
obliged to resort as he proceeds. We do not feel that he can deviate 
from a safe course in completing the entire journey if an accurate 
chart of each portion is presented. The different steps are: 

1. Incision of the abdominal wall; 

2. Puncture, emptying, and removal of the cyst ; 

3. Management of adhesions ; 

4. Management of the pedicle ; 

5. Toilet of the peritoneum ; 
G. Drainage. 

A description of the abdominal incision will be found in the 
chapter on Technique. 

Incision of the peritoneum should be made between two dissect- 
ing forceps, which hold it away from the abdominal contents and 
avoid danger of injuring the cyst or coils of intestine. The perito- 
neum incised, the pearly, glistening surface of the cyst is exposed ; 
when there are adhesions the finger should be introduced as a guide 
to guard against injury to the cyst or to intestine. At the lower part 
of the wound it will recognize the bladder and prevent it being 
wounded. The peritoneum may be overlooked and cut through, 
and the omentum mistaken for preperitoneal fat; in the latter the 
vessels are transverse, in the former vertical. Where the perito- 
neum is firmly fastened to the parietes of the cyst it may be diffi- 
cult to determine when it is reached. The cyst-wall should be 
incised, the cyst emptied, and an attempt made to withdraw the 
posterior wall ; or the abdominal incision may be continued to the 
umbilicus, where the layers of the wall are fused together, when the 
cyst-wall will be more easily recognized. As a prelininary step to 
further procedure after the peritoneum is incised, it may be fastened 
to the integument by one suture about the middle of either side of 
the wound. This procedure prevents its being pushed off from the 
abdominal walls during the further manipulation. 

Emptying the Cyst. — The cyst projects into the wound, present- 
ing a pearly, glistening appearance. The trocar, with a rubber tube 
attached long enough to dip into a receptacle placed beneath the table, 
is plunged into the cyst, choosing a point for its introduction which 
will empty the large or main cyst and is free from large vessels. 
This puncture should not be made at the lower angle of the wound, 
for the reason that as the cyst empties it retracts and leaves the 






DISEASES OF THE OVARIES. 595 

opening situated below the wound, increasing the difficulty of 
preventing the fluid from flowing into the abdomen. As the trocar 
is plunged into the cyst the abdominal walls are held close about it, 
and sponges should be packed around the orifice to prevent any 
fluid running back into the peritoneal cavity. As the sac becomes 
relaxed it is grasped with hemostats, and later with cyst-forceps, 
and drawn out, keeping the opening in the cyst outside the abdom- 
inal wound. The assistant will place his hands upon either side 
of the abdomen or upon its upper part, making pressure which forces 
out the fluid and keeps the wound stretched over the projecting sur- 
face of the cyst. If there are a number of cysts, the trocar may be 
passed from one into the other. In this procedure, however, it is 
important that the hand should be passed into the abdomen around 
the cyst to prevent the trocar from perforating its main wall, injur- 
ing the viscera or abdominal tissues, or permitting the escape of fluid. 
Where a trocar of suitable character is not at hand, the parts may 
be drawn tense around the cyst, puncture made into it with a knife, 
the edges grasped with forceps, drawn out, and the orifice thus kept 
outside the abdominal cavity. Other cysts may be opened through 
the first cyst, and their cavities broken down by the hand passed 
through the opening. This, in some cases, may be necessary, owing 
to the consistency of the fluid being such that it will not readily flow 
through the trocar. In small cysts it is preferable to introduce the 
hand and break up the cysts rather than to attempt to pass the trocar 
in different directions to empty them. As the cyst is emptied it is 
also drawn out, so that in a single cyst, or in a m unilocular cyst 
which is not adherent, the emptying is followed or partially preceded 
by the withdrawal of the sac. Where the cyst has thick, viscid 
contents, it may be necessary to draw it well up into the wound 
before opening it, or possibly, after turning the patient upon her 
side, to press back the abdominal wall from the under side, open 
the cyst, and, dragging the opening still farther out, break up the 
contents. In this way a cyst of considerable size may be brought 
through a small opening. Where there is considerable solid 
material in the cyst, however, requiring some difficulty to bring 
it through the opening, the latter should be enlarged, rather than 
to subject the patient to much manipulation in order to avoid a 
large opening. In dermoid cysts or those in which suppuration 
has occurred it is better that a larger opening should be made and 
the cysts be removed entire. When the contents of dermoid cysts 



596 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

flow into the abdominal cavity it is exceedingly difficult to remove 
them and to neutralize their irritating effect. The material is oily 
in character, and does not wash out readily by irrigation ; for such 
reasons it is preferable that the cyst should be removed intact. 

Adhesions. — The ease with which adhesions may be managed 
depends much upon their character. In recent cases, where the 
cyst has undergone inflammatory action, resulting in adhesive peri- 
tonitis, the adhesions may readily be overcome by the use of the 
sponge. It is sometimes recommended to introduce the hand into 
the abdominal cavity before the cyst is punctured and separate or 
break up the adhesions. This can readily be done over the anterior 
parietes, where the adhesions are soft, but dense, firm adhesions should 
preferably be separated at the wound under the guidance of the eye. 
Consequently, after the cyst has been wholly or partially emptied, 
it is drawn out, and where adhesions of a soft and friable character 
exist, these are separated by pressing the viscera off from the sac by 
a sponge. Adhesions will depend in gravity upon their situation 
and duration. The older the adhesions, the more thoroughly or- 
ganized they become and the more difficult they are to separate, 
requiring, in some cases, the use of the scissors or knife. Parietal 
adhesions, where they cannot be sponged off, may be separated by 
the finger, tearing the surfaces from the cyst-wall, or, where this 
cannot be accomplished, by using the scissors. Not infrequently 
considerable bleeding will take place. Omental adhesions are fre- 
quently long and quite vascular, so that they are preferably tied 
with a double ligature and cut between, using for this purpose 
fine silk. Adhesions that are difficult to manage are those 
between the intestine and other abdominal viscera and the cyst- 
wall. Such adhesions may involve coils of the intestine, the stom- 
ach, the spleen, the liver, and the gall-bladder. Adhesions to 
some of these organs are exceedingly firm and only separated 
with considerable difficulty. Where the adhesions are long they 
may be separated by means of the scissors or by grasping the 
adhesions with a clamp and burning through the tissues with 
the cautery. When the adhesions to the intestine, for instance, 
are sessile, the removal of the neoplasm may be attended with con- 
siderable difficulty. In some cases adhesions are very close, and their 
removal would involve the structure of the bowel, impairing its vital- 
ity. It is then preferable that the cyst-wall should be cut through, 
leaving a portion of it attached to the intestine, taking the precaution 






DISEASES OF THE OVARIES. 597 

to remove the epithelial lining membrane, thus taking away the 
entire secreting surface of the cyst. Pelvic adhesions of long dura- 
tion are the most difficult to manage and the most dangerous in 
character. A tumor which has been situated low down in the 
pelvis, filling it, may be adherent to the large arterial or venous 
vessels. The author never had a more trying or sadder experience 
than in a woman of sixty-three years of age, the mother of a phy- 
sician, who had a thin-walled cyst, which was completely emptied, 
and was only adherent in the pelvis. On making gentle traction 
upon the cyst, endeavoring to push off the pelvic tissues, there was 
at once a sudden filling up of the entire pelvis with venous blood, 
showing that a large vein had been injured. The hemorrhage was 
controlled by packing the pelvis with sponges, removing the blood, 
but the patient was already profoundly shocked. After the removal 
of the sponges the pelvis was packed w ith iodoform gauze, which 
was brought out at the lower angle of the wound. She lived but a 
few hours after the completion of the operation. 

In some cases the adhesions will be found extending into Doug- 
las's cul-de-sac, requiring an universal enucleation. In parova- 
rian or broad-ligament cysts we may find the broad ligament 
spread out and covering the cyst- wall. In such cases it is import- 
ant to examine carefully the tissues as we progress, for the tumor 
may be found to have begun its development deep in the broad 
ligament, and may have pushed above it the ureter, as was found 
by the author in one case of broad-ligament cyst : after opening 
the cyst and commencing to enucleate, the ureter was found to pass 
directly over it. Attempted enucleation would have been attended 
with so much injury to the ureter as to have imperilled its vitality. 
For this reason the tumor was completely emptied, irrigated and 
with a view of securing drainage, stitched to the abdominal wound 
and its cavity packed with iodoform gauze, in order to set up inflam- 
matory changes within it to destroy its secreting surface and lead to 
adhesion of its walls. In this, however, we regret to say, the opera- 
tion was not a success, as the patient appeared a few months later 
having a cyst fully as large as the one for which we had operated. 

Papillary cysts may develop beneath the broad ligament, and 
infiltrate the tissues to such a degree as would render their removal 
almost impossible, or, if removal were performed, would leave a 
large, ragged, raw surface which necessarily increases the danger to 
the patient. In bleeding following the separation of extensive adhe- 



598 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

sions, not arrested by irrigation with hot water, it may be necessary 
to use the Paquelin cautery. Where the adhesions have been to 
the anterior parietes in very large cysts, large raw surfaces are 
exposed ; that is, the peritoneum is torn through. The bleeding 
may be controlled and unfortunate intestinal adhesions avoided by 
introducing sutures through the abdominal wall in such a way as to 
approximate the large raw surfaces and thus shut them out of the 
abdominal cavity and promote their union. 

Pedicle. — After emptying and drawing out the cyst, the 
empty sac is found to be attached to the abdominal cavity by 
a more or less narrow band of tissue which is known as the 
pedicle. It consists in the majority of cases of the ovarian 
ligament, a part of the broad ligament, with not infrequently the 
tube extending over the cyst. There has been much discussion 
in the past upon the proper treatment of the pedicle — whether it 
should be treated intra- or extra-peritoneally ; in other words, 
whether it should be ligated or the vessels otherwise secured and 
dropped back, or should be brought out and fastened in the lower 
angle of the wound. In the latter method of treatment it has been 
the custom to use the clamp. This clamp method for many years 
was practised by Atlee, Wells, and contemporary operators. Its 
advantage was the security against hemorrhage and the fact that 
the pedicle was constantly under observation. It had the disad- 
vantage of requiring a longer time for convalescence ; the pedicle 
sloughed off, increasing the danger of septic infection, leaving a sur- 
face to heal by granulation, and in some cases has resulted in subse- 
quent menstruation from the stump. The intra-peritoneal method 
is that which is now universally practised. The pedicle may be 
ligated, or cauterized as has been recommended by Keith. Cauteri- 
zation is performed by grasping the tissue of the pedicle in a 
clamp, one side of which is covered with ivory plates to pre- 
vent the heat being conveyed to the tissues beneath, and sear- 
ing the included tissues by cautery-iron heated to redness. The 
method is not to be used under any circumstances where it is pos- 
sible to place a ligature. Operators universally prefer the use of 
the ligature. The pedicle, when of ordinary size, is transfixed and 
tied in two portions. The ligament should be transfixed with a 
double ligature, cut, and each half tied separately and then both 
the ends together, or one ligature may be carried around, tying it 
over both parts. Where we have a large tumor made up of solid 



DISEASES OF THE OVARIES. 



599 



material, which it would require considerable effort to hold and pre- 
vent traction upon the pedicle, the latter may be seized with pedicle 
forceps immediately beneath the cyst, to secure the patient from loss 
of blood, and the tumor cut away, after which the pedicle may be 
tied in the manner we have already described. In removing the 
tumor it is important to leave a sufficiently long stump above the 
ligature to prevent the possibility of a portion of the tissue being- 
retracted, permitting hemorrhage to take place from either the 
ovarian or uterine arteries. For ligation of the pedicle either silk 
or catgut may be used. The catgut is preferred by some operators 
for the reason that it, being an animal ligature, is absorbable and 
will not remain to give rise to irritation subsequently. Its disad- 
vantages are that the ligature may slip, affording an opportunity 
for hemorrhage to occur after the wound has been closed, and the 
catgut being septic may cause infection of the peritoneal cavity. 



Fig. 321. 




*^Si 




Triple Interlocking Ligature; the threads 
interlocked ready for tying. 



Where the pedicle is a broad one and a short stump is left above 
the ligature, it is preferable to introduce a second one about that 
portion of the pedicle through which the ovarian artery passes, 




Triple Interlocking Ligature tied. 



so that in case the ligature should slip this large vessel would still 
be controlled. An illustration of this procedure is given in Fig. 
279. A broad, fleshy pedicle should preferably be tied in a num- 
ber of sections, the ligatures being introduced and tied as seen in the 
accompanying figures. Or, better still, an en masse ligature may be 
placed about the uterine end of the ovarian artery, a second one 



600 AN JlMERICAN TEXT-BOOK OF GYNECOLOGY. 

about the opposite end of the same artery placed close to the pelvic 
wall and introduced deep enough to include the round ligament and 
its accompanying artery. The pedicle is cut away. Any space in 
the broad ligament intervening between the two ligatures is then 
whipped together by a continuous catgut sature. After the removal 
of a cyst and ligation of the pedicle the operator should examine 
the condition of the other ovary, and should it show signs of cyst- 
growth, it is also to be removed. In some tumors, particularly the 
broad-liganuent and parovarian cysts, no pedicle will be found. 
These tumors dip into the broad ligament alongside of the uterus. 
In such cases it will be necessary to peel out the cyst, and ligate any 
vessels that may be found to bleed, or, if the bleeding be from a 
large surface rather than from distended vessels, it may be controlled 
by gauze packing. This may be accomplished at times without re- 
moving the ovary or tube. 

Peritoneal Toilet. — Where a simple uncomplicated cyst has been 
removed the necessary toilet of the peritoneum is slight. It consists 
in sponging out the pelvic cavity or in introducing a sponge to ascer- 
tain that there is no sign of bleeding, when the cavity may be closed. 
Where adhesions have been extensive, it is important to examine 
carefully to see whether or not bleeding still continues, and, if so, to 
take measures to control the hemorrhage. If the omentum has been 
torn from the cyst and shows signs of bleeding, it should be placed 
upon a towel wrung out of hot water, carefully examined, and bleed- 
ing points ligated with catgut. All bands of adhesion or openings 
in the omentum should be tied and cut away, as they only afford an 
opportunity for a knuckle of intestine to slip through and thus 
endanger the patient from obstruction of the bowel in the subse- 
quent convalescence. Where there has been much bleeding and 
the abdominal cavity has been soiled with discharges from multi- 
locular or papillary cysts, it should be thoroughly irrigated. The 
preferable fluid for this purpose is a 0.6 per cent, solution of com- 
mon salt, of which, if necessary, several gallons may be used. The 
solution is made by adding forty-eight grains of salt to the pint of 
water, and should always be rendered sterile by boiling prior to use. 
After irrigation the superfluous fluid may be removed by sponging, 
or if the drainage-tube is used it may be left. A flat sponge is 
placed beneath the wound, over the intestines, in such a way as to 
cover them and keep them back while the sutures are introduced. 

Drainage. — Before closing the wound we must consider the sub- 



DISEASES OF THE OVARIES. 601 

ject of drainage. When shall drainage be used? If used, what 
shall be its character? What shall be the method by which 
it will be accomplished ? The question of drainage is one 
which has been much discussed of late years, some operators 
advocating that every case should be drained, others none. 
Larger experience has demonstrated that drainage may be most 
frequently omitted. Even in those cases in which the peritoneal 
cavity has been soiled by discharge from suppurating cysts, the 
sponging away, and in case any be left the dilution of the poison, 
usually renders it inert or gives the peritoneum ample opportunity 
to destroy and absorb it. Irrigation with large quantities of salt 
solution and closing the cavity with a large quantity remaining is a 
proper method of procedure. Cases in which injuries of the intes- 
tine have occurred of such a character as to render leakage possible 
should be drained. 

As to the form of drainage : a glass tube, as illustrated in the con- 
sideration of Technique, is by many preferred. The perforations at 
the bottom of the tube should be perfectly smooth, depressed rather 
than elevated, and small, to prevent the entrance of the intestinal 
walls by intra-abdominal pressure, rendering the removal of the 
tube difficult and painful, and increasing the danger of lighting up 
inflammation. The objection to the glass tube is that it requires 
frequent emptying, and is an open avenue for the entrance of patho- 
genic germs into the peritoneal cavity. Another method of drain- 
age is the gauze drain, which is also described under Technique. 
Its advantages are that the possibility of entrance of septic infection 
is lessened. When the drain is removed, which may be at the end 
of twenty-four to seventy-two hours, it may be replaced by a steril- 
ized rubber tube. The abdominal wound is closed as described in 
the chapter on Technique. 

The method of managing patients after ovariotomy will be found 
described in the chapter on After-treatment. 

Accidents during the Operation— Stripping off the Parietal 
Peritoneum. — This accident is not likely to occur where care is 
observed. The operator may overlook the .peritoneum, and, sup- 
posing that it has been opened, push it off from the abdominal walls. 
This is especially so in chronic accumulations of free fluids in the 
peritoneal cavity accompanied by thickening of the parietal perito- 
neum as in tubercular peritonitis. More frequently, however, it is 
likely to be opened without being recognized, and the omentum be- 



t)02 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

neath regarded as the preperitoneal fat. As has already been 
observed, this may be avoided by noticing that the vessels in the 
transversalis fascia run transversely, while those in the omentum 
are vertical. When the omentum is fastened over the tumor, it is 
better to find its point of attachment and tear it up, rather than to 
open through the omentum itself, on account of the probability of 
bleeding. The peritoneum may be stripped off during manipula- 
tion, as in the introduction of sponges to keep the surfaces dry dur- 
ing the introduction of the sutures. 

Rupture of the Cyst. — In delivering the cyst, particularly where 
the walls are fragile, it may be torn through, permitting the contents 
to escape into the abdominal cavity. This is not an accident of seri- 
ous importance unless the contents of the cyst are putrid in cha- 
racter, as in suppurating cysts, or, again, in the dermoid varieties, 
where the oleaginous material is exceedingly difficult to remove from 
the cavity. Tearing of the wall of the cyst during its removal 
necessitates a thorough irrigation of the abdominal cavity to neu- 
tralize or remove the contents. 

Fatal Hemorrhage. — Fatal hemorrhage during operation was 
formerly an event of greater frequency than it has been of late. 
The site of the hemorrhage will have much to do with its character : 
in large cysts with extensive adhesions we may have hemorrhage 
taking place from the cyst itself or from vessels that may be torn 
within its walls, giving rise to a serious condition. In such cases the 
course of treatment should be to separate adhesions rapidly, lift out 
the cyst, secure its pedicle, and so cut off the supply of blood. In 
separating adhesions the larger and more vascular should be cut 
between two ligatures or between a ligature and a pair of hemostats. 
If the hemorrhage is of a serious character, the assistant may place 
his hand within the abdomen and compress the abdominal aorta, 
maintaining the pressure until after the operation is completed. 
Such a procedure prevents further supply of blood being sent to 
the tumor, and so arrests the bleeding. We may find hemor- 
rhage take place from a very extensive surface, particularly after 
the removal of malignant disease, or extensive papillary growths 
behind the uterus, involving its entire posterior surface and the 
pelvic viscera. In a recent case the diseased tissues were hurriedly 
removed, and the cavity and bleeding surfaces above were com- 
pressed by a number of antiseptic towels packed into the abdom- 
inal cavity. This thoroughly controlled the flow, but the patient 



DISEASES OF THE OVARIES. 603 

was so enfeebled prior to the operation, and still further exhausted 
by the loss of blood, that she died shortly afterward. Fatal 
syncope and death may take place in very large tumors from the 
decreased abdominal pressure. Vessels relieved from pressure be- 
come distended by the blood, forming reservoirs, until so much 
is withdrawn from the circulation that the resulting cerebral 
anemia is sufficient to cause the death of the patient. In such 
cases the patient may be said to have bled into her own vessels. 
Such an occurrence is only likely to take place in very large 
tumors, and may be obviated by emptying the cyst slowly. When 
syncope occurs the head should be lowered, the limbs wrapped in 
warm blankets or bandaged, and an assistant may compress the 
aorta directly with the hand in the abdominal cavity, while the 
treatment of the pedicle and the toilet proceeds. It may at times 
become necessary to remove the uterus on account of the free bleed- 
ing from its torn and denuded surface. Such a procedure will not 
infrequently spare the patient the dangers incident to drainage. 

Visceral Injuries. — Injuries to the viscera, particularly the intes- 
tines, are likely to occur during complicated operations. It is im- 
portant before opening the peritoneum to lift it up with forceps, and 
make a small incision into which the finger can be introduced. 
The importance of doing this under the eye can be appreciated 
when we remember that a coil of intestine may be situated between 
the tumor or cyst and the abdominal parietes, adherent to the lat- 
ter, when an incision blindly made might result in cutting into or 
through the intestine. Where adhesions are dense the intestine 
may be torn into or even across during the progress of the opera- 
tion. Where such lesions occur the parts should carefully be 
repaired at once, and measures exercised to prevent soiling of the 
peritoneal cavity with the contents of the bowel. The intestine 
should be carefully sutured, and, when torn through to such a 
degree as to render the vitality of the parts uncertain, its resec- 
tion and an end-to-end or lateral anastomosis should be practised. 
Where the operator is prepared with the Murphy button an end-to- 
end anastomosis is very quickly accomplished. In the absence of 
these buttons, an end-to-end anastomosis may be done by simple 
suturing of the surfaces, beginning with sutures between the muscu- 
lar surfaces, and then a second row around the peritoneum, so that 
considerable peritoneal surface is opposed. The most difficult cases 
to suture are those in which the rectum has been torn during 



! 



604 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

the operation. Portions of the bowel may be so devitalized that 
they subsequently slough, giving rise to fecal fistula, In tumors 
situated low in the pelvis, those that have developed in the broad 
ligament, and particularly in the papillary forms of ovarian growth, 
it is quite important to keep in mind the position and relation of 
the ureter, as this organ may be pulled up or torn off in the enu- 
cleation of such masses. Where the situation of the ureter is such 
as to render its injury possible, it is better to dissect it out to make 
sure it is uninjured ; where it has been cut or torn, the preferable 
procedure is to establish an anastomosis with the bladder. Where 
the ureter is short and likely to be too much drawn upon, the blad- 
der should be anchored to the side of the pelvis in the most favor- 
able position to relieve the tension on the ureter. If the bladder 
and ureter cannot be safely approximated, an end-to-end anasto- 
mosis of the severed ureter should be made. (See chapter on Diseases 
of Bladder, Urethra, and Ureters.) A case has been referred to which 
came under the observation of the writer in which the ureter passed 
directly over the upper surface of a large cyst, and came very near 
being cut or torn in two during the effort at its enucleation. The 
bladder may be situated in such a position that it may be injured 
during the abdominal incision or during the progress of the opera- 
tion. Thus, where the bladder is drawn up by contact with the 
cyst and spread out over its anterior surface, it may be overlooked 
before its true character is suspected. The entire fundus of the 
bladder has been cut away in the removal of cysts. It has been 
the misfortune of the operator to open into the bladder before he 
realized its true character. The peculiar interlaced muscular struc- 
ture of its wall should cause it to be recognized. Wherever 
the bladder is opened or injured it should be sutured. In a 
case in which the entire summit of the bladder was cut away the 
walls were sutured, opposing a good extent of the peritoneal sur- 
faces and the patient recovered. In such injuries it is important 
also to prevent the bladder becoming unduly distended during the 
convalescence, especially for the first few days. It should be 
emptied frequently, in order that the accumulation may not lead 
to separation of the weak union and consequent leakage of urine. 

Incomplete Operations. — We are unable by our most accurate 
rules of examination always to arrive at a correct and definite dia- 
gnosis of either the disease or the structures involved. 

An incision of the abdomen may reveal that a tumor is so situ- 



DISEASES OF THE OVARIES. 605 

ated or so extensively adherent to surrounding structures as to 
render its removal impossible. Incomplete operations were formerly 
much more frequent than at present. Indeed, there are few cases 
in which an operation for the removal of a tumor should be dis- 
continued after it has been once begun. In those cases, however, in 
which an exploratory incision discloses that the disease is malignant, 
and has already infiltrated tissues which cannot be safely removed, 
or secondary nodules are found in tissues remote from its origin, the 
acquisition of such knowledge should be considered a bar to further 
procedure. If upon opening the abdomen it is found that the entire 
peritoneal cavity is studded with papillary growths resulting from 
infection of the peritoneum through the rupture of a papillary cyst, 
it would be unwise to subject such a patient to the danger incident 
upon the removal of the original source of the disease. 

The cases in which complications too grave to permit of the com- 
pletion of the operation exist may be subjected to mere closure of the 
wound where the parts have not been much disturbed ; in others it 
may be necessary to drain : this may be done by a glass or rubber 
tube or by the gauze drain. Where a cyst has been opened, 
or in any case in which it has been injured, but is found con- 
nected with other tissues by adhesions so firm as to render re- 
moval impracticable or unwise, the cyst may be opened, emptied of 
its contents, brought up and stitched into the abdominal wound. 
The superfluous portion should be cut away. The cavity may be 
packed with iodoform gauze, which promotes drainage, and by its 
presence in the sac may lead to an inflammation which will cause 
its obliteration. 

Sequels. — The subsequent progress of a patient who has been 
subjected to ovariotomy will depend much upon the manner in 
which the operation has been conducted. In spite of every pre- 
caution that may be taken, there will be some cases of delayed con- 
valescence, possibly due to some latent or pre-existing pathological 
tendency ; but when an operation is carelessly performed and its 
details are imperfectly carried out, the probability of serious trouble 
can be appreciated. The operator and his assistants should have so 
trained themselves that the slightest deviation from a proper course 
cannot go unnoticed. Of what avail is it to spend much time in 
securing cleanliness of person, room, and instruments, and then 
drag the ligature with which the pedicle is to be secured over 
blankets or dirty tables before its introduction ; to dust the wound 



606 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

with iodoform from a box that has been standing open and used in 
all sorts of cases about a ward ; to rub the nose, scratch the head, 
or touch other non-sterilized objects, and place the hand in the 
cavity without any precautionary cleansing ? Such indiscretions will 
often explain stitch-abscesses and other septic processes. Pus-col- 
lections and cellular inflammations will occur in the pelvis about 
and posterior to the uterus, due possibly to some infection of serous 
collections in Douglas's pouch. Elevation of temperature, rapid 
pulse, and pain continued after the fourth or fifth day should lead 
to a careful examination for its origin. A mass of exudation in the 
pelvis should be considered an indication for the administration of 
salines in free doses until purgation, and the use of rectal and vag- 
inal enemata of hot water at least twice daily. The exudation 
should be carefully watched, and the appearance of softening, felt 
either through vagina or rectum, should be considered as requiring 
prompt evacuation. The latter is accomplished by an opening 
through the vault of the vagina behind the uterus. The vagina 
should have been carefully disinfected, and the pus-cavity should 
be irrigated with normal salt solution or sterilized water and packed 
with iodoform gauze. 

Intestinal Complications. — After operations for conditions compli- 
cated by inflammatory troubles intestinal sequelae are not infrequent. 
It is difficult to make sure the intestines are free from twists when 
replaced, but danger is aggravated when we have bands of inflam- 
matory adhesions, or openings in the omentum or mesentery, beneath 
or through which a knuckle of intestine may slip and become strangu- 
lated. Laceration of the coats of the intestine will affect its peri- 
staltic action, and may lead to paralysis of a section, with ensuing 
symptoms of obstruction. A twist or volvulus may become so fixed 
that nothing can pass through it. If the walls are already weakened, 
a fecal fistula may ensue, as has occurred in our experience during the 
past year. A woman, much prostrated by puerperal sepsis, was sub- 
jected to abdominal section, the pus evacuated, forming as it did reser- 
voirs in front and behind the uterus, and the abdomen was irrigated 
and drained. She did well for a few days, when a discharge of feces 
occurred, and upon her death some weeks later a volvulus was 
found. In a case operated upon at the Philadelphia Hospital by 
a colleague obstruction occurred five weeks after operation. The 
patient was seized with stercoraceous vomiting. A resection was 
performed, and five feet of intestine torn up, finding at its base a 



DISEASES OF THE OVARIES. 607 

•distinct volvulus, which was untwisted. The patient recovered 
after a prolonged convalescence. The importance of early reopen- 
ing the abdomen in such cases cannot be over-estimated, as the 
obstruction may be due to strangulation of a knuckle of intestine 
beneath inflammatory bands or to its enclosure between the sutures 
in the wound. 

Adhesions. — It is quite probable that no case subjected to abdom- 
inal section is subsequently free from adhesions, though their fre- 
quency and extent will depend somewhat upon the presence of sep- 
sis. The more aseptic the operation and the less the peritoneum is 
injured, the slighter and more fragile will be the adhesions. 

They are more likely to take place between the abdominal 
incision and the underlying viscera, and between the stump of the 
pedicle and adjoining coils of intestines. The former may be ren- 
dered less annoying by drawing down the omentum to protect the 
wound, and the stumps may be turned forward and stitched to the 
anterior fold of the broad ligament. Dusting a film of aristol over 
the intestines to prevent adhesions has been recommended, but the 
procedure is of little practical use. Where adhesions have formed 
pain may be caused by traction upon them during the peristaltic 
action of the intestines. Pain thus caused has been so great that 
patients have submitted themselves to subsequent operation for 
relief. It is questionable how much is gained by such attempts, 
as whenever adhesions are broken up new injuries are produced, 
which increase the danger of inflammation and additional adhe- 
sions. 

In all secondary operations the possibility of adhesion to the 
cicatrix should be kept in mind, and the incision should be pro- 
longed upward to obviate the danger of injuring the intestine. 



DISEASES OF THE URETHRA, BLADDER, AND URETERS. 



Methods of Examination. 

Inspection. — Without using instruments the only portion of the 
urethra which can be examined is the meatus urinarius externus and 
a small portion of the canal which lies immediately above it. We 
here note the shape of the orifice, whether intact or everted, its color, 
the presence of tumors or ulcerated areas or of a purulent discharge. 
The lips are then drawn apart and the orifices of " Skene's glands," 
which open just within the meatus, are examined for any evidences 
of inflammation. 

While no portion of the bladder or ureters can be inspected 
directly without the use of instruments of some sort, the lower ab- 
dominal zone may show a rounded tumor or prominence above the 
symphysis pubes where the bladder is dilated or hypertrophied. 

By the use of instruments we obtain the most reliable results in 
studying the diseases of the urethra, bladder, and ureters. The 
essential features of the examination are — (1) atmospheric distention 




of the bladder secured by position, (2) the introduction of a simple 
straight open speculum, and (3) the inspection of the mucous sur- 

fiOS 



DISEASES OF URETHRA, BLADDER, AND URETERS. 609 

faces of the bladder, urethra, and ureteral orifices by means of 
a light reflected into the bladder. 

Instruments. 

The necessary instruments for such an examination are — (1) a set 
of Kelly's cystoscopes, (2) a conical dilator, (3) a suction apparatus, 
(4) a pair of delicate mouse-tooth forceps with long shanks, (5) a 
searcher, (6) applicators, (7) ureteral and renal catheters, and (8) a 
reflecting mirror and a good light. 

The cystoscopes are nickel-plated cylinders, 8 centimeters long 
and equal in diameter from end to end. These cystoscopes are made 
of varying diameter, and a complete set will contain cystoscopes 
increasing in size from a small one measuring 6 to a large size 




measuring 12 or 14 millimeters, and it will be found conveni- 
ent, if much work is to be done, to have cystoscopes measuring 




Suction Apparatus. 

respectively, 8£, 9|, and 10^, millimeters, these intermediate sizes 
often being useful. 

The applicators are instruments shaped like the searcher, but 
roughened on the ^nd to allow of their being wrapped with cotton. 

The light is a most important adjunct, and its intelligent use will 



610 



AN AMERICAN TENT-BOOK OE GYNECOLOGY. 



go far toward making the examination successful. An electric drop- 
light with an oval tin reflector painted white is the best to work 
with, as it can be more easily managed and held close to the body, 



Delicate Mouse-touthed Forceps. 

and the light is steadier. If, however, this is not obtainable, a gas 
or oil lamp can be used with good results. 

The reflecting mirrors are like those used by the laryngologists, 
and should be about three inches in diameter. 




Ureteral Searcher. 



For the examination of the ureters long flexible catheters are 
used ; these are made of braided silk, coated with varnish and rubbed 



. of long flexible Ureteral or renal Catheter. 



perfectly smooth. They are made in two lengths, the short ones,. 
30 centimeters long, being spoken of as ureteral catheters, the long 
ones, 50 centimeters, being the renal catheters. The diameter varies 
from If to 3 millimeters, and they are numbered according to the 
measured diameter. 

Metal ureteral catheters are also used to catheterize the lower 

Fig. 330. 



Metal t'retcnil • 'atbeter. 



portion of the ureter, and those of larger caliber can be employed 
as dilators for strictures in the lower portion of the ureter. 



DISEASES OE URETHRA, BLADDER, AND URETERS. 611 

The Previous Preparation of the Patient. 

The patient should have had the bowels well moved before any 
examination is attempted. The clothes around the waist must be 
loosened or removed, and the corset should always be taken off. The 
urine must be passed immediately before she is placed in position on 
the table, and the bladder is more apt to be completely emptied if 
the urine is voided standing or if a catheter is used and the bladder 
is squeezed out bimanually. 

The room where the examination is to take place is so arranged 

Fig. 331. 




that it may be darkened at will, the examining table being either 
a plain wooden table covered with a thin mattress or a regular office 
table. 

The instruments are placed on another table near the examiner's 
hand. 

The knee-breast position is the most useful one in the majority 
of cases. The buttocks and legs of the patient are covered with a 



612 



AN A3IERICAN TEXT-BOOK OF GYNECOLOGY. 



sheet, in which there is either a long slit or a square opening to 
prevent unnecessary exposure. The labia are gently separated, and 
the genitals, especially the meatus, are carefully washed with a bo- 
racic solution, and then an applicator wrapped with cotton and 
moistened with a 10 per cent, solution of cocaine is introduced a few 
moments into the urethra ; or in place of the applicator a small 
pledget of cotton moistened with the same solution may be laid 
against the urethral orifice. This is allowed to remain in place four 




Searching for the ureteral orifice with the patient in the dorsal position. 



or five minutes, then removed, and the patient is ready for examina- 
tion. 

The use of an anesthetic is usually not necessary, though where 
this is the first examination, especially with nervous patients, anes- 
thesia will be of great assistance. 

The patient may be also examined in the dorsal position, the hips 
raised six or eight inches above the table, bags filled tightly with 
bran being placed under the buttocks. In thin women this position 
is more practicable, but with a large, stout woman it will often be 
found impossible to get the bladder well dilated, and in any case the 
examination is much more difficult than with the patient in the 
knee-breast position. 



DISEASES OF URETHRA, BLADDER, AND URETERS. 613 

The Introduction of the Cystoscope and Examination of 
the Bladder and Urethra. 

The patient being in position and ready, the examiner separates 
the labia, and, first measuring the size of the urethra with the coni- 
cal dilator, determines which cystoscope can be most easily intro- 
duced. The cystoscope is then grasped, the handle being held in 
the fingers, the thumb pressing steadily against the handle of the 
obturator, holding it in position and preventing it from sliding back 
when the cystoscope is introduced ; the end is lubricated with boro- 
glycerin solution, and it is ready for introduction. 

With the patient in the knee-breast position the general direction 
of the urethra is nearly directly horizontal ; and this is the direction 
in which the cystoscope is held and introduced, a gentle curve being 
described around the under surface of the symj)hysis. It should 
after passing the meatus glide easily and with but little resistance. 
A mistake which is almost always made at first is the attempt to use 
cystoscopes of large diameter, these hardly ever being introduced 
without exerting much force and hurting the patient greatly; there- 
fore, if the cystoscope which was at first tried will not pass easily, a 
smaller one should be used. 

If it be necessary, the urethra may be safely dilated to a diame- 
ter of 14 or 15 mm., the only bad result being slight laceration of 
the external meatus, incontinence never resulting where no greater 
dilatation than this is attempted. 

The dilatation is best carried out by using the graduated Hegar's 
dilators or the conical dilator before described. Anesthesia will 
almost always be found necessary in these cases. 

As soon as the cystoscope is introduced the obturator is with- 
drawn, and the air rushes into the bladder, and distends it with an 
audible suction sound. The light is held by an assistant in such a 
manner as to make the angle of reflection the smallest possible, and 
the mirror is maneuvred so as to keep the pencil of light constantly 
-thrown into the bladder during the examination. The first point 
viewed when the obturator is removed, if the bladder is well dilated 
with air, is the posterior wall. 

It is best to always have a routine system to follow in bladder 
examinations, and there must be some landmarks to allow of de- 
scription and for reference in future examinations or treatment. 
These landmarks may be divided into (1) artificial, (2j natural. 



614 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

Artificial. — The two points, the internal urethral orifice and that 
part of the posterior wall opposite to it, may be referred to as the 
anterior and posterior poles of the bladder ; and with these as cen- 
ters the bladder-walls may be divided into an anterior and posterior 
hemisphere and quadrants by imaginary lines bisecting the two 
poles ; we can thus speak of changes occurring, for instance, in the 
upper posterior left quadrant, and at the next examination will be 
able to locate again the same area by reference to our imaginary lines. 

Another method, which although not so definite is simpler, is to 
divide the bladder into the vault, the anterior, the posterior, and two 
lateral walls, and the base. 

Natural Landmarks. — These are the internal urethral orifice, 
the ureteral eminences, the two ureteral folds, and the interureteric 
fold. 

The internal urethral orifice may be recognized by withdrawing 
the speculum until the urethra commences to close over the end, and 
then pushing it in again for about ^ centimeter. 

The ureteral orifices are important landmarks, and with the pa- 
tient in the knee-breast position are often found at the summit of a 
small eminence, or the so-called " mons ureteris." The ureteral 
fold or ridge is formed by the lower end of the ureter in its passage 
through the bladder-wall, and another landmark is the interureteric 
fold or ridge, which is found extending from one ureter to the 
other, and forms one boundary of the vesical triangle, or the " tri- 
gonum vesicae." 

The normal groundwork of the bladder as it appears through the 
cystoscope is of a dull whitish color, everywhere divided by a net- 
work of branching vessels. 

By elevating and depressing the handle of the cystoscope and 
moving it from side to side all parts of the posterior hemisphere can 
be brought into view. By moderately elevating the handle of the 
cystoscope the vault of the bladder is seen, and, as a rule, there will 
be found here a few cubic centimeters of urine which must be 
removed by the suction apparatus before all the parts can be dis- 
tinctly seen. 

The trigonum is brought into view by withdrawing the cysto- 
scope until the internal urethral orifice just begins to close over it, 
and then pushing it in slightly. This portion of the bladder is 
always a little more injected and rosy than the rest of the mucosa. 
The ureteral orifices may be found by turning the cystoscope about 



DISEASES OF URETHRA, BLADDER, AXD URETERS. 615 



30° to the right or left, with the end projecting about 1 or 2 era. into 
the bladder. 

The urethra can be viewed from end to end as the cystoscope is 
withdrawn from the bladder : the walls fall together and form a 
funnel-shaped figure over the end of the instrument. The color of 
the normal urethra is a rosy-red, darker in brunettes, and exhibits 
radiating bands slightly lighter in color. 

On closer inspection the orifices of the small urethral glands are 
seen, being more thickly placed on the lateral walls. 

Palpation. 
The whole length of the urethra can be palpated through the 
vagina, and it is noted whether on pressure pus can be squeezed out, 

Fig. 333. 




Squeezing pus out of the urethra with the finger in the vagina. 

then whether there is any tenderness present, either localized or 
general ; the shape and consistency of the urethral tube, whether 
more rigid than normal or increased in thickness, and whether it 
can be rolled under the finger or is fixed by periurethral changes. 
The base of the bladder may be palpated with the finger in the 



I 



616 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



vagina, and thickening of the bladder-walls or the presence of for- 
eign bodies may be made out by bimanual palpation, with the patient 
either in the usual dorsal position or with the patient in the knee- 
breast position. 

Examination of the Ureters. 

No portion of the ureters can be examined visually, save the urete- 
ral openings into the bladder, unless an exploratory incision be made. 
We have at our disposal two methods of examining the ureter : 

Fig. 334. 




Pelvic Portion of the Ureter viewed from below, 

(1) Indirect, by means of the ureteral catheter or bougie; (2) By 
direct palpation through the vagina, the rectum, and the abdominal 
wall. 

Indirect Examination. — The cystoscope is introduced as de- 
scribed, the orifice of the ureter located, and cleansed, if necessary, 
with a small pledget of cotton held in the mouse-tooth forceps. 



J5 fe- 
55 2. 



$* g 




^ 





I 



DISEASES OF URETHRA, BLADDER, AND URETERS. 617 

India-rubber firiger-cots are then placed on the thumb and fore 
finger of the hand to be used, and the long or short ureteral catheter 
is guided through the cystoscope and into the ureteral orifice, the 
point having been previously moistened with the boroglyceride solu- 
tion. The assistant supports the outer end of the catheter, prevents 




Pelvic Portion of the Ureter viewed from above. 

it from touching the head or face of the examiner, and slowly with- 
draws the wire stylet as the catheter advances. But little force is 
necessary to carry the catheter upward, the feeling as soon as the 
orifice is passed being that the catheter is in a large free space. 
By this means strictures of the ureter are discovered and local- 
ized. Stones lodged in the ureter may be detected in this way, and 
any distortion or twisting of the uretef*will be seen in the shape 
that the catheter takes on its removal. The urine from the side 
catheterized is also collected and examined for any abnormal con- 
stituents. 



618 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



Direct Palpation. — By the vagina the lower portions of the ure- 
ter, from its point of entrance into the bladder to the lateral and 
posterior walls of the pelvis, can be easily palpated, especially if 
changed and hardened by disease ; and by the rectum it may be 
felt in its course along the posterior wall nearly or quite to the brim. 

The abdominal portion of the normal ureter can only rarely be 
palpated directly through the anterior abdominal wall, but not 
infrequently a ureter hardened and thickened by disease can be so 
palpated, and almost always in ureteral inflammatory disease ; 

Fig. 336. 




Course of the Ureters marked on the Abdomen. 



marked tenderness can be elicited on pressure on points about 3 cm. 
(1 inch) to the right or left of the promontory of the sacrum, which 
is first located by deep palpation. 

Diseases of the Urethra, 
malformations. 
Complete Absence of the Urethra. — This is a very rare condition, 
and is usually accompanied by other abnormalities of the genito- 
urinary tract. 



DISEASES OF URETHRA, BLADDER, AND URETERS. 619 

The bladder opening is generally seen as a transverse slit on the 
anterior vaginal wall, and there is in most cases incontinence of 
urine, though occasionally the urine can be retained for a short 
time. 

Partial Absence of the Urethra. — In this condition only a por- 
tion of the urethra is defective, the defect being either of the exter- 
nal or internal portion. If of the internal urethra, there is usually 
incontinence of urine, as the neck of the bladder is apt to be 
involved. 

Hypospadias. — This is an absence of more or less of the inferior 
wall of the urethra, the anterior and part of the lateral walls being 
present, forming a groove where the urethra should naturally lie. 

The condition varies greatly in degree, from the cases where the 
urethral orifice is only slightly displaced to those where the orifice 
is found in some position on the anterior vaginal wall, and is not to 
be seen on inspecting the external genitalia, the urine appearing to 
be discharged from the vagina. 

Another variety of hypospadias is seen where there is persistence 
of the sinus uro-genitalis. In these cases there is only one open- 
ing present between the perineum and the clitoris, this being the 
outer ending of a canal which divides above to form the urethra 
and vagina. 

Atresia. — This occurs as a congenital condition affecting either 
the whole urethra or only some portion of it. The urethra also 
may only be separated from the bladder by a thin septum, the sep- 
tum being usually found at the junction of the urethra and bladder. 

In some of the cases there exists an opening at the umbilicus 
through a patulous urachus, by which the fetus during its intra- 
uterine life discharges the urine, and the same condition will persist 
after birth as a patulous urachus, unless an opening is substituted 
below by operation. 

Frequently, however, the fetus with a urethral occlusion has no 
avenue for the discharge of the urine, and the abdomen in such 
cases becomes so much distended as to require puncture before the 
delivery can be effected. In these cases there is, besides the marked 
dilatation of the bladder, double hydroureter and hydronephrosis. 

Teeatment. — Many of these affections do not call for treatment, 
either occasioning death during the intra-uterine period or being 
associated with other such serious malformations of the genitals as 
to exclude entirely the idea of any curative treatment. 



620 AN AMERICAN TEXT-BOOK OE GYNECOLOGY. 

The defects in the urethral wall may be closed by a plastic ope- 
ration, taking flaps from the vaginal wall and forming with them a 
canal which should be a little larger than the normal canal to allow 
or the subsequent contraction. 

Atresia, if due to a septum, may be perforated with a small trocar 
and cannula, thus establishing a communication which may be 
enlarged subsequently. 

Other methods of treatment will be suggested by the character 
of the case. 

Prolapse of the Urethral Mucosa. 

Cause. — This condition is most frequently seen in young chil- 
dren, though it has also been noticed in women past the middle age. 
It appears following severe attacks of coughing or from straining at 
stool, and vesical calculi, urethritis, and rectal irritation from pres- 
sure, hemorrhoids, or prolapsus are also frequently associated with 
it. In women it is usually an eversion of that part of the mucous 
membrane lying adjacent to the external orifice. In little chil- 
dren, on the contrary, the eversion is from the deeper urethra, 

Symptoms. — Frequent and painful micturition and tenderness 
about the urethral triangle are the chief symptoms. It is also fre- 
quently attended by painful coitus and may interfere with walking. 

Diagnosis. — As the symptoms are not diagnostic, a visual exam- 
ination is necessary. The prolapsed portion of the urethral mucous 
membrane appears as an intensely red, highly vascular tumor, in 
the center of which the urethral opening is found. In children the 
tumor is apt to be more prominent, and is usually of a deeper red 
or bluish color. If the prolapsus is of long standing, the mucous 
membrane may present a glazed, dry, or excoriated surface. 

A condition of prolapse of one or the other of the ureteral emi- 
nences has been noted, simulating prolapse of the urethral mucosa ; 
the diagnosis is, however, easily.made by the presence of the ureteral 
orifice, and by the use of a small probe, which shows, when passed 
between the prolapsed portion and the urethral wall, where the 
eversion begins. 

Treatment. — In recent cases, especially in children, after the 
prolapsed mucosa is replaced the patient should remain in bed for 
a few days, and astringent urethral suppositories or topical applica- 
tions of dilute carbolic acid or iodine may assist in retaining the 
mucous membrane in situ. 



DISEASES OF URETHRA, BLADDER, AND URETERS. 621 

The bowels should be kept loose, as straining at stool always 
increases the prolapsus, and the bladder should be carefully explored 
for stone, tumors, or polypi. 

If the condition is persistent and does not yield to local treat- 
ment, the redundant mucous membrane should be excised and 
the external and urethral edges brought together by fine silk su- 
tures. The sutures must be passed through the urethral mucosa 
before the incision is made to prevent retraction of -the severed 
into the urethra. 



Dilatation of the Whole Urethra. 

Causes. — This condition frequently follows unwise attempts to 
explore the bladder by rapid dilatation and the introduction of the 
index finger. It has been occasioned by dragging a large stone out 
of the bladder through the urethra, or by the spontaneous expulsion 
of large stones or pieces of tumor. 

It is not uncommon in women suffering with either congenital or 
acquired atresia of the vagina, coitus being practised per urethram ; 
and there are also instances where the dilatation was due to the daily 
insertion into the urethra of wax candles or other large bodies for 
the relief of sexual excitement. 

Symptoms. — Persistent incontinence of the urine and the irrita- 
tion of the surrounding parts are the most trying symptoms, but, 
curious to state, in the cases in which the dilatation has been due to 
coitus per urethram there is rarely incontinence, the urine only 
escaping on coughing or some sudden exertion. 

Diagnosis. — This will be made as soon as the labia are separated 
and an examination attempted, the finger slipping into the dilated 
urethra while searching for the vagina, the dilatation being in some 
instances great enough to allow two fingers to be inserted through 
the urethra into the bladder. 

Treatment. — The relaxation due to coitus should not be touched 
unless the vaginal canal can be restored, especially as the symptoms 
•occasioned by this form are apt to be slight. If operative help is 
decided on, an area on each side of the external urethra may be 
divided and sutures passed in such a way as to produce tension, lift- 
ing the posterior wall of the urethra firmly up against the anterior. 
In this way the urine is held back until the obstruction is overcome 
by pressure from above. 

The best method, however, of treating this condition is by excis- 



622 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

ion of a portion of the anterior vaginal wall and of the posterior 
wall of the urethra, the excised portion of the urethral wall meas- 
uring 4 or 5 mrn. in breadth. The edges of the wound are brought 
together by silkworm-gut or silk, the sutures holding together the 
edges of the urethra being carefully placed, approximating the 
edges of the wound exactly, and not entering at any spot the lumen 
of the canal. 

The incontinence may also be controlled in some cases by using 
a pessary which will press against the urethra. 

Partial Dilatation of the Urethra. 

This condition is also known under the name of " urethrocele " 
or " sacculated urethra," and is usually situated in the middle third 
of the canal. 

Causes. — Stricture or lessening of the caliber of some portion of 
the canal, either by a hypereinic condition of the mucosa or by 
pathological changes following inflammation, and pressure on the 
urethral wall behind the obstruction following from the retained 
urine. Childbirth may also be a cause, the pressure of the child's 
head during delivery bruising or wounding the middle portion. 

Forms. — The muscular wall may be thickened and hypertro- 
phied around the sacculated portion, this form being usually seen 
where there is some obstruction to the outflow. On the other hand, 
the sacculation may be due to a prolapse of the mucosa through the 
muscular coat. 

Symptoms. — Frequent desire to micturate, with perhaps some 
incontinence of urine on exertion. In some cases, besides the fre- 
quent desire, a straining or difficulty in micturition will be seen. 
There are also the symptoms of urethritis present, as this condition 
usually accompanies the urethrocele. 

Diagnosis. — This can be made by passing into the urethra a 
sound with the point bent slightly downward, the area and degree 
of dilatation being mapped out between the sound and a finger in- 
serted into the vagina. This lesion must not be mistaken for a 
simple prolapse of the anterior vaginal wall, the difference being 
easily made out when the sound is introduced : as in prolapse of the 
vagina, the axis of the urethra is in the normal direction. A cyst 
in this position can also simulate an urethrocele, but the differential 
diagnosis is made by the relations which are demonstrated by the 
sound. 



DISEASES OF URETHRA, BLADDER, AND URETERS. 623 

It can be differentiated also from a suburethral abscess by the 
symptoms, the prominent tumor, and the pain on walking or coitus. 

Treatment. — If only of slight degree, astringent bougies or 
applications, with relief of a stricture or other local condition, will 
usually effect a cure. 

In the more marked cases the only method of relief is by ope- 
ration. A wedge-shaped piece of tissue over the dilated portion is 
excised, removing the surplus tissue, including the whole thickness 
of the septum. The edges of the wound are brought together by 
silkworm-gut sutures, and a catheter is retained in the canal for two 
or three days. 

Steictuee of the Ukethra. 

The strictures seen in the female urethra are generally circular 
and more or less localized, though they may affect the whole canal. 
They are of uncommon occurrence. 

Causes. — Ulceration of the urethra as the result of chancroid or 
a very severe gonorrheal infection is apt to cause a localized stricture 
by the subsequent contraction of the scar. 

Injury to the urethra during childbirth is also a frequent cause 
of stricture, as are other varieties of trauma. 

Tubercular ulceration may also cause a narrowing of the lumen 
in one or more areas. 

Neoplasms of the urethra are rare causes, though in the early 
stages, before ulceration has set in, they may narrow the urethral 
lumen. 

General narrowing of the urethral canal may be the result of a 
severe urethritis or periurethritis, the tissues being the seat of a small- 
celled infiltration and subsequent contraction. There may also be 
narrowing due to carcinomatous or sarcomatous infiltration of the 
tissues around the canal. 

' Symptoms. — In a large majority of the cases no symptoms are 
complained of, and the condition is only discovered accidentally. 
In a certain number of cases, however, the complaint of frequent 
and difficult micturition, gradually increasing, is made, and in rare 
cases there is incontinence, or, on the other hand, there may be 
infrequent micturition, at times approaching retention. In cases 
of long standing, cystitis or dilatation of the bladder may result. 

Diagnosis. — As the symptoms are not sufficiently suggestive, the 
urethra should alwavs be examined. A vaginal examination usu- 



624 AN AMERICAN TEXT- BOOK OF GYNECOLOGY. 

ally shows thickening at some point on the anterior wall corre- 
sponding with the course of the urethra, If a sound be introduced, 
it will meet with resistance at this point, and it may be impossible 
to pass it farther. 

Prognosis. — This should always be guarded, as the stricture will 
again occur unless it can be dilated at intervals. Cystitis or dilata- 
tion of the bladder is always a dangerous symptom and gives a more 
unfavorable prognosis. 

Treatment. — Gradual dilatation should be practised by means 
of Hegar's dilators, starting with one of the small sizes and gradu- 
ally increasing the size until a No. 10 or 12 is reached. Care 
should be used not to rupture the urethra by too rapid dilatation, as 
incontinence may result from such an accident. Very rarely, when 
the cicatricial tissue is dense and unyielding, division of the strict- 
ure according to " Otis' method " in stricture in the male may be 
required. 

In the rare cases where the stricture cannot be dilated an open- 
ing between the urethra and the vagina behind the stricture may 
be made, and the edges of the urethral mucosa stitched to the vag- 
inal mucosa by fine silk sutures. In making this incision the neck 
of the bladder must be carefully avoided, as otherwise incontinence 
will result. 

Urethritis. 

Causes. — In a large majority of the cases the urethritis is due to 
a gonorrheal infection, and is only part of a general infection of 
the genital tract. In other cases the inflammation is due to the 
presence of the tubercle bacillus. In other cases, again, the ure- 
thritis follows a trauma, as in childbirth, a suppurative or diph- 
theritic cystitis, or inflammation of the neighboring organs. There 
is also a certain mild form of urethritis seen in women where 
there has been no opportunity for infection by contagion, and where 
there can be no suspicion of gonorrhea, and which runs its course 
in a few days. 

Symptoms. — In the milder forms of urethritis the principal 
complaints are of a burning pain on micturition, of an increased 
frequency in the desire to pass the urine, and of a slight purulent 
urethral discharge. There is also some tenderness on pressure on 
the urethra, and perhaps swelling and a slight tendency to pro- 
lapse of the swollen mucous membrane. 



DISEASES OF URETHRA, BLADDER, AXD URETERS. 625 

In the gonorrheal urethritis there is at first, following the infec- 
tion, an itching sensation in the urethra, followed in a day or two 
by the sensation of burning or stabbing pain on micturition, and 
generally increased frequency of the desire to void the urine. If 
the urethra is examined during the first day or two, very little can 
be made out : there is a slight serous or sero-purulent discharge 
from the meatus and some pain on pressure. Later the discharge 
becomes purulent, and on pressure can be squeezed out of the ure- 
thra, appearing at the meatus as a yellowish drop. 

The meatus will be found reddened, the edges everted with a 
tendency to slight prolapse of the mucosa, and if a speculum be 
introduced the whole urethral mucosa is found reddened and much 
swollen. On pressure through the vagina the urethra is tender. 

Tuberculosis of the urethra is usually seen as an ulcerated area, 
and it is almost always secondary to bladder tuberculosis, and 
the symptoms are therefore apt to be masked by the bladder 
condition. 

Diagnosis. — This should be based on the symptoms, the burn- 
ing pain on micturition being quite characteristic. A visual exam- 
ination should also always be made, noticing first the condition of 
the meatus, then with the finger in the vagina pressing on the ure- 
thra and noting the pain, and also whether pus can be squeezed out. 
The pus squeezed out of the urethra should always be examined 
microscopically, determining in this way the presence of the gono- 
coccus or other organism present. 

A local examination should always be insisted upon, as the symp- 
toms are usually not characteristic enough to allow of a differentiation 
between urethritis and certain forms of cystitis, and it is of great 
importance in the treatment that this differentiation be made. 

Teeatmext. — In the very acute forms rest in bed is necessary. 
A light, easily digested diet should be ordered, advising also the 
use of some mineral water to lessen the acidity of the urine, or the 
citrate of potash, taken in 20 gr. doses three or four times a day, 
may be used for the same purpose. Locally, hot applications to the 
vulva or the hot vaginal douche, containing, if there is a suspected 
gonorrhea, the bichloride of mercury in solution, should be ordered. 

Later urethral irrigations may be practised, using dilute solutions 
of the bichloride of mercury or of nitrate of silver. 

Medicinal agents may also be applied to the urethra in very soft 
ointments, being introduced through a small-sized cvstoscope. 



626 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

.In the chronic forms, where there are ulcerated or granulating 
areas, local application through the cystoscope of weak nitrate-of- 
silver solutions is the best form of treatment. 

Suburethral Abscess. 

Cause. — This condition is quite rare, and the cause is uncertain, 
though it is usually attributed to distention and ulceration of one 
of the glands in the floor of the urethra, or in other cases to rup- 
ture of fibres of the urethra, with a sagging at this point, where the 
urine accumulates and decomposes, occasioning inflammatory changes 
and abscess-formation. 

Symptoms. — Usually painful micturition, gradually increasing 
in severity, and a discharge of ammoniacal urine or pus on chang- 
ing the position or on coitus. Pain during coitus and the presence 
of a painful tumor in the vagina. 

Diagnosis. — This is easily made by examination, there being 
found in the anterior vaginal wall a tender ovoid fluctuating tumor,, 

Fig. 337. 




1 

G 
Urethral Diverticulum, containing pus and residual urine. 

which partially disappears on pressure, the pus being squeezed out 
into the urethra. It can be differentiated from cysts of the vaginal 
wall by the tenderness and by its communication with the urethra, 
and from a " urethrocele " by the great tenderness, the presence of a 
circumscribed tumor, and the general symptoms. 

Treatment. — The best method is by excision, removing an ellip- 
tical piece of the vaginal mucosa, and carefully dissecting out the 
whole cyst-wall down to the urethra, which is left intact, followed 
by immediate closure of the wound by silkworm-gut sutures. 

A slower method is by an incision through the abscess-wall, the 
cavity being packed with gauze, thus keeping the incision open and 
allowing it to heal by the formation of granulation tissue. 



DISEASES OF URETHRA, BLADDER, AND URETERS. 627 

Neoplasms of the Urethra. 
The portion of the urethra most apt to be affected is the exter- 
nal orifice, though growths in other portions are not uncommon. 

The neoplasms are divided into (1) the benign, and (2) the 
malignant neoplasms. 

Caruncle. 

This is a tumor usually located at the external meatus, involving 
one or both lips and appearing as a raspberry-red tumor, ex- 
quisitively sensitive and bleeding readily upon touch. 

Symptoms. — As the growth is usually exquisitively sensitive, the 
acute pain on micturition is easily explained. There is also great 
pain on coitus, simulating at times a condition of vaginismus, and in 
some cases there is pain on walking. The bleeding is small in 
amount, never giving rise to free hemorrhage. 

These tumors are made up of connective tissue in which courses 
an extensive network of blood-vessels covered by flattened epithelial 
cells. 

It is not precisely known to what the sensitiveness is due — 
whether, as is most jjrobable, to an unusual nerve-supply, or whether 
to the baring of the nerve-endings by the destruction of the epi- 
thelium of the surface. 

Treatment. — Excision is the only treatment which will give relief. 
This may be done under cocaine anesthesia, any hemorrhage which 
may appear being controlled by the sutures which are passed imme- 
diately, bringing together the edges of the wound. 

A better result is obtained by using general anesthesia, as the 
growth may then be more carefully removed and better coaptation 
of the edges of the wound will be obtained, as the patient is per- 
fectly quiet. 

Condylomata. 

Causes. — These warty growths are usually found in connection 
with similar disease of the other parts of the external genitals, and 
are most frequently seen in cases of gonorrhea, though they are 
occasionally present where there is a non-specific irritating discharge. 
Filth and dirt are also causes. 

Symptoms. — The small growths give rise to no symptoms ; the 
larger growths are troublesome only from their size. 

Diagnosis. — This is easily made from an inspection of the exter- 
nal genitals. The growths, usually multiple, are of a pale pinkish 



628 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

color, usually tipped with white, more or less pedunculated, and 
with a tendency to confluence and the formation of large tumors. 
The microscopical picture is that of a warty growth, the ground- 
work of the tumor being connective tissue in which the blood-ves- 
sels are distributed ; the layer of epithelium covering it is increased 
in thickness. 

Treatment. — Each condyloma is to be snipped off with a pair 
of sharp scissors, and the bleeding point touched with the thermo- 
cautery. The larger growths may either be removed by the thermo- 
cautery or with the knife. If the knife is used, the thermo-cautery 
or a few fine silk sutures will be necessary to control the hem- 
orrhage. 

Urethral Polypi. 

These are rare growths, sometimes appearing in the adult and 
sometimes being congenital. They may be multiple, or only a single 
tumor may be present, consisting of a groundwork of closely packed 
connective-tissue fibers, covered with several layers of pavement epi- 
thelium and having the same appearance as fibromata elsewhere. 

Treatment. — They may be removed with the curette and scis- 
sors, or, if there is only a single one deeply seated in the urethra, 
a snare may be used. 

Cysts of the Urethra. 

Causes. — These are usually formed by the occlusion of the ori- 
fice of a urethral gland. They are not limited to any one age, and, 
though not extremely rare, are uncommon. 

Symptoms. — The cysts are apt to occasion difficulty in micturi- 
tion, and if situated near the external orifice may protrude through 
it, giving rise to a tumor which must be differentiated from prolap- 
sus, caruncle, or fibroma. 

Treatment. — Puncture of the cyst, or, if it is troublesome, re- 
moval by urethrotomy, the wound in the urethra being closed imme- 
diately by fine silk sutures. Care must be taken that in introducing 
the sutures they do not pass entirely through the mucosa and enter 
the lumen of the urethral canal. 

Congenital Malformations of the Bladder. 

Complete Absence of the Bladder.— -This is a very rare condi- 
tion, and in most cases it is rather a marked atrophy of the organ 
than a complete absence. If the bladder is, however, completely 



DISEASES OF URETHRA, BLADDER, AND URETERS. 629 

absent, the ureters open either into the urethra or into the rectum. 
Usually, as most of these cases are accompanied by other marked 
abnormalities, the child is either dead born or dies soon after 
birth. 

Double Bladder. — Cases of true division of the bladder into two 
halves are exceedingly rare, and it is probable that most of the cases 
described as double bladder by the older authorities were, in fact, 
cases of extreme sacculation. There have been, however, some cases 
reported where there was undoubtedly a division of the bladder into 
two halves. Usually the septum runs antero-posteriorly, there being 
one ureteral orifice present in each half. The urethra opens into 
either the right or left half, and there is an opening in the septum 
to allow the urine to pass from the other half into the urethra. The 
condition of double bladder, besides the sacculation above spoken of, 
which is usually the result of disease or of displacement, may be 
simulated by a dilated urachus, though from the position this is 
easily recognized. 

It is also possible for a congenital cyst in close proximity to the 
bladder to simulate a supernumerary bladder. 

Xone of these conditions demand any treatment, the condition 
being only discovered at the autopsy table. 

Extroversion or Exstrophy of the Bladder. — This anomaly is far 
more frequent in the male than in the female sex, it occurring about 
once in the female in every five cases seen. The abnormality varies 
greatly in degree. According to Guterbock, the following forms 
may occur : 

(1) A diastasis of the abdominal muscles and of the symphysis 
pubes, the bladder, covered by the normal skin, projecting through 
this opening. 

(2) A diastasis of the muscle, symphysis, and skin, the closed 
bladder projecting from this opening, connecting, however, in the 
usual manner with the normal urethra. 

These two forms are usually classed as hernia of the bladder, 
though they evidently arise in the same manner as the more marked 
forms of extroversion. 

(3) The true extroversion is divided into (a) '* fissura anterior 
totalis vesicae," and (b) "fissura anterior partialis vesica?," which is. 
a much rarer form, the opening being either above at the upper 
portion of the bladder or below near the base. Under this second 
form mav be classed also the patulous condition of the urachus. 



630 AN AMERICAN TEXT-BOOK OE GYNECOLOGY. 

On examining these cases of true extroversion a separation of 
the abdominal walls and of the symphysis pubes will be found, the 
space between the pubic bones being either slight or extensive, and 
either filled in with fibrous tissue or existing as an unobstructed open- 
ing. In the opening thus formed will be found the bladder pushed 
forward by the viscera crowding down upon the posterior surface. 
It appears as a red, spongy-looking mass, usually encrusted in places 
by the urinary salts, or there may be ulcerated spots in various parts 
of the wall. The ureteral orifices will be found either at the sum- 
mit of small eminences or perhaps hidden in a fold of the bladder- 
wall, and there will be seen every few moments a spurt of urine 
from one or the other side. The clitoris is usually found divided, 
lying on the two sides of the opening, although in some cases there 
is entire absence of any attempt at the formation of this organ. 

The vagina may be normal or may appear as an elongate trans- 
verse fissure. 

The uterus and its appendages are usually normal. 

Symptoms. — The symptom complained of most bitterly is the 
constant flow of urine over the surrounding parts, giving rise, unless 
great cleanliness is osberved, to troublesome excoriations. The con- 
stant urinous odor which always attends these patients is also a great 
source of mortification. 

Pain is also complained of from the irritation and rubbing of 
the clothes on the protruded bladder, and there is apt to be slight 
hemorrhages from this source. There is also apt to be inflammation 
of the mucosa with ulceration, and this adds to the discomfort from 
the pain and profuse purulent discharge, as well as to the danger to 
life from an ascending ureteritis and pyonephrosis. 

Treatment. — The treatment of this anomaly is a subject of no 
little importance, from the great distress occasioned by the constant 
dribbling of the urine and the excoriation of the parts. In all cases 
the treatment, whether operative or mechanical, is only palliative, 
as the function of the bladder cannot be completely restored. Vari- 
ous mechanical devices have been employed for conducting the urine 
away from the bladder, but they are usually unsatisfactory, and the 
repair of the defect by a plastic operation should always be at- 
tempted. On account of the impossibility of keeping the field asep- 
tic, failure is frequent, and many operations may be required to 
accomplish the result desired. 

A number of ingenious operations have been devised for exstro- 






DISEASES OF URETHRA, BLADDER, AND URETERS. 631 

phy of the bladder, but those employing a central flap made from 
above, with lateral flaps, appear to be the most advisable. Thiersch's 
operation embraces these principles, and is frequently successful. 
The deformity of the urethra should first be corrected before the 
vesical defect is repaired. 

The method as devised by Thiersch consists, first, in the lifting 
up of a flap from the centre of the abdomen above the opening. 
This flap should be of sufficient size to close the bladder, and must 
have a pedicle. The edges of the abdominal opening are freshened, 
and the flap is brought down in such a way as to throw the skin sur- 
face against the mucous membrane of the bladder. The margins 
of the flap are then stitched to the denuded edges of the abdominal 
opening. 

Bridge-like flaps are dissected up from the inguinal region on 
either side of the opening, leaving both ends attached. Iodoform 
gauze is packed beneath these flaps until granulation springs up 
and the nutrition of the parts is well established, when the upper 
ends may be cut and the flaps pushed over upon the granulating- 
surface of the central flap and secured in place by suture. In this 
way the first flap is reinforced and the lateral edges of the divided 
opening are protected. In all these cases there will be incontinence 
of urine, as the sphincter muscles are absent, and so far no method 
of treatment has been advanced to replace their function. For this 
reason some form of ambulatory urinal is required. 

Thiersch, in order to do away with the necessity of using a urinal 
in women, has established an artificial channel from the bladder to 
the rectum. This is not advisable, as the rectum is not tolerant to 
urine, and if it loses its function the condition of the patient is 
more deplorable than it was in the beginning. 

Billroth advises making a small opening through the central flap, 
as the recti muscles often close the opening sufficiently to retain the 
urine. Skin-grafting may be used if the skin does not extend to 
the center of the flap. 

Preceding operations for the restoration of extroversion, the sur- 
rounding parts must be restored to a healthy condition by the lib- 
eral use of the zinc-oxide ointment. The urine should be kept 
bland by the proper drugs if it tends to produce irritation. The 
general nutrition of the patient should be carefully looked into, and 
no operative measures instituted before she is in good health. If 
the operation be successful, some form of ambulatory urinal may be 



632 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

prescribed, and the patient is able to live more comfortably, as the 
excoriation and inflammation of the surrounding parts, the disgust- 
ing odor and constant dribbling of urine, are obviated. 

Displacement of the Bladder. 

These may be divided into — (1) Upward displacement, (2) Down- 
ward displacement, (3) Prolapse of the bladder. 

Upward displacements of the bladder are most frequently observed 
in large myomatous tumors of the uterus, where, as the tumor de- 
velops, the bladder is dragged up with it. 

Symptoms. — There are usually no symptoms complained of, 
though occasionally there may be frequent urination. 

Treatment. — The only method is by the removal of the tumor. 

Downward Displacements of the Bladder. — This condition is seen 
in its mildest grade, where, with a laceration of the perineum, there 
is a tendency to downward displacement. The so-called cystocele 
or prolapse of the anterior vaginal wall, which is so common in mul- 
tiparous women, must not be confused with this condition. 

A more marked displacement is seen accompanying partial or com- 
plete prolapse of the uterus, and rarely, with complete prolapsus of 
the uterus, the whole bladder may be displaced outside of the body. 

Symptoms. — As there is in these cases almost always some resid- 
ual urine, there is apt to be a cystitis present. There is usually, 
too, complaints of inability to pass the urine, and in some cases the 
uterus and bladder have to be replaced by the hand before the urine 
can be passed. Calculi may also form in the dependent portion of 
the sac. 

Diagnosis. — This can be easily made by passing a somewhat 
curved sound into the bladder, and with this finding its limits above 
and in the prolapsed portion. 

Treatment. — This is the same as that for prolapsus uteri — 
namely, amputation of the cervix if necessary, repair of the relaxed 
vaginal outlet, and possibly suspension of the uterus to the anterior 
abdominal wall. 

Prolapsus of the Bladder through a Patulous Urethra. — This 
condition is rarely seen, and is most probably due to a trauma 
or severe strain. 

Symptoms. — The presence of a tumor at the urethral orifice, incon- 
tinence of urine, pain and tenderness on walking and moving, and 
probably inflammation of the prolapsed portion. 



DISEASES OF URETHRA, BLADDER, AND URETERS. 633 

Diagnosis. — This may be made by the appearance of the tumor, 
one or both ureteral orifices being seen on it, and by passing a sound 
along the side of the tumor it will be found to enter the bladder. 

Treatment. — After the prolapse is reduced the patient should 
remain on her back for some days. The bowels must be carefully 
regulated, and the urethra, if not much dilated, may be reduced in 
size by the use of astringent suppositories or applications. 

If the urethra is much dilated, a plastic operation for the narrow- 
ing of its lumen must be practised. 

Foreign Bodies in the Bladder. 

Foreign bodies may gain entrance to the bladder — (1) from above, 
through the ureter ; (2) from below, through the urethra ; (3) from 
ulceration through the bladder- wall ; or (4) calculi may be formed 
in the bladder itself. 

The foreign bodies entering the bladder from above, through the 
ureter, are usually calculi, though blood-clots, clots of inspissated 
pus, or small echinococcus cysts may also enter the bladder from 
the kidney or ureter. 

The foreign bodies gaining entrance through the urethra are 
either catheters which have been introduced by physicians and slipped 
into the bladder suddenly, or they are bodies introduced by the 
patient herself, such as hairpins, knitting-needles, bodkins, stems of 
grass, etc. 

Foreign bodies gaining entrance through the wall of the bladder 
are rarer than the other varieties. They may enter the bladder 
from the vagina by ulcerating through the partition walls ; for 
instance, a pessary may gain entrance in this manner. Teeth and 
hair from a dermoid cyst have also been found in the bladder, as 
have fecal concretions from an appendicitis which has ruptured into 
this viscus. The commonest foreign bodies which gain entrance 
through the bladder-wall are sutures or ligatures which have been 
used during operations on the uterus or other pelvic organs. 

In fractures of the pelvis small pieces of bone may be forced 
through the bladder-wall or through a rupture of the wall into the 
vesical cavity. 

Calculi formed in the bladder itself are the most common foreign 
bodies, and may either be composed of the earthy phosphates, urates, 
or uric acid, or several of these ; the other varieties of vesical cal- 
culi are more rare. 



634 AN A3IERICAN TEXT-BOOK OF GYNECOLOGY. 

Symptoms. — Usually during the first few hours no symptoms are 
present; after the lapse of from twelve to twenty- four the usual 
symptoms of a cystitis — namely, greatly increased frequency of mic- 
turition, with probably bladder tenesmus, the passage of bloody 
urine, and with constant pain in the vesical region — will make them- 
selves apparent. 

Diagnosis. — This, in a certain number of the cases, will be easily 
made from the history of the case ; in a certain percentage, how- 
ever, no history at all can be obtained of the introduction of the 
foreign body into the bladder, and the physician must make the 
diagnosis from a general study of the patient, from sudden acute 
onset of the symptoms with no apparent cause, by a vaginal exam- 
ination, feeling for the foreign body through the vaginal walls, and 
lastly by a cystoscopic examination. 

Treatment. — There are three ways of removing from the bladder 
a. foreign body — namely, (1) through the urethra ; (2) by an incision 
through the vaginal walls into the bladder; or (3) by the "section 
alta " or suprapubic cystotomy. 

Removal through the urethra method should always be attempted 
first, especially if the body is long and narrow, as a glass catheter, 
bodkin, hairpin, etc. The operator introduces one or two fingers 
in the vagina, attempting to engage one end of the body in the 
internal urethral orifice ; if this can be done, it may either be pushed 
on with the vaginal finger or caught by a pair of forceps introduced 
into the urethra and pulled out in this manner. 

Articles which are soft and easily bent may also be removed 
through a medium- or large-sized cystoscope, using for the purpose 
a special pair of forceps or a small tenaculum. When the above 
method fails entrance into the bladder through the vagina may be 
practised. The anterior vaginal wall is exposed, and an incision 
through the wall in the median line is made, thus exposing the wall 
of the bladder, which is then opened, taking care that the incision 
through the bladder does not touch or include the internal urethral 
orifice. The foreign body is caught with forceps and removed, the 
wound being closed in the same manner as a vesico-vaginal fistula. 

Vesical Calculus. — Vesical calculi rarely occur in women, 
because of their short and patulous urethrse. Renal calculi which 
are expelled into the bladder, and in men often form the nucleus for 
a much larger stone, are in women swept out during the first mic- 
turition. It is probably very seldom that a stone descends from the 



DISEASES OF URETHRA, BLADDER, AND URETERS. 635 

"kidney and remains a sufficient time in the female bladder to gain 
by accretion a size which prevents its expulsion through the 
■urethra. The fact that a large proportion of calculi in women 
are discovered after the repair of vesical fistulse goes to prove that 
they are formed in the bladder, and are not simply the enlargement 
of stones from the kidney. After vesico-vaginal operations, if the 
stitches are allowed to pass through the mucous layer of the blad- 
der, it is probable that the nidus for the stone may be furnished by 
the exposed suture. Emmet claims that such operations are the most 
frequent source of stone in women. Calculi may be of various kinds, 
as uric acid, urates, triple and amorphous phosphates, oxalate of lime, 
or cystine. Phosphatic stones are more frequent in women than in 
men, while those of uric acid are less frequent. It is rather difficult 
to account for this difference in their occurrence in the two sexes, 
but it is possibly due, as explained by a number of writers, to the 
more frequent tendency of men to a gouty or lithemic diathesis. 
Foreign bodies introduced for various purposes by hysterical women 
may form the nucleus of a stone. Thus, hair-pins, bits of wax, 
buttons, beans, etc. have been found as the centre of vesical calculi. 
Usually the bladder contains but a single calculus, but occasionally 
two or more are found. The most common shape is a flattened ovoid, 
although they may be somewhat rectangular or irregularly rounded, 
while phosphatic stones are occasionally curiously branched. 

On account of the patulous urethra in women, calculi of small 
dimensions are rarely found ; they vary from the size of a pea to 
that of a walnut and are often much larger. The density of the 
calculus depends upon its chemical composition, the phosphatic 
variety being the most friable and easily crushed. The situation 
of the stone varies with the position of the patient. When she 
is in an upright position, it will usually be found at the base of the 
bladder or blocking the orifice of the urethra, but if recumbent the 
stone will drop back toward the fundus. It may be encysted or 
caught by a fungous mass or retained between the rugae of an 
hypertrophied bladder-wall. If there be a diverticulum in the 
bladder, as is often seen accompanying prolapsus uteri, the stone 
will be found at the bottom of this sac. Occasionally it is lodged 
in the orifice of an ureter. The author removed a stone within the 
last two years which he had previously located in the mouth of the 
left ureter by means of the ureteral sound. 

Etiology. — The causes of calculi are obscure. The reason for 



636 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

the deposit of urinary salts about a foreign body is perfectly patent,, 
but the origin of a stone in the centre of which no foreign body can 
be found is not so clear. 

In those cases of prolapsus uteri in which a vesical diverticu- 
lum exists, calculi are prone to form, as these sacs usually contain 
residual urine, and when one observes, under the microscope, the 
manner in which urinary crystals are often entangled in the shreds 
of mucus, it may quite as reasonably be expected that the same 
result will take place in the diverticulum of the bladder, thus lead- 
ing to the formation of a calculus. 

Symptoms. — The symptoms which are most characteristic of 
stone are frequent micturition, with sudden stoppage in the flow, 
hematuria, and pain. An irregular, halting, and painful flow of 
urine is, of all symptoms, the most characteristic. It usually 
occurs when the stone is small, and is sucked into the vesical mouth 
of the urethra, acting as a ball-valve. As it grows in size this 
tendency often entirely disappears. Frequent micturition is usually 
a constant symptom, the patient being compelled to void her urine 
many times during the day, especially when she is on her feet or 
doing active work. During the night this urgent and frequent 
desire to void the urine disappears, and the patient may pass a 
whole night without once getting up. Horseback riding or driving 
over rough roads often causes severe pain. 

The pain in vesical calculus is of two kinds — that directly caused 
by the stone, and that produced by the cystitis which almost inva- 
riably follows as the result of vesical irritation. There is constant, 
heavy, dull pain over the pubes, radiating down into the legs and 
external genitalia and upward to the groin. The pain, which is 
characteristic, is sharp and lancinating, and occurs at the end of 
micturition, frequently being referred to the external genitalia, and 
is so severe at times as to cause the patient to scream. Violent 
straining accompanies micturition, and the attending pain may be 
referred to the rectum or perineum, especially if there are hemor- 
rhoids or if prolapsus of the rectum exists, as frequently results 
from the straining efforts. 

In little girls the pain may be entirely referred to the vulva, -and 
lead to a habit of constantly dragging or picking at the parts, which 
causes hypertrophy and excoriation of the labia. 

Hematuria is frequent, but is characteristic only when a few drops 
of bright-red blood appear at the end of micturition. 



DISEASES OF URETHRA, BLADDER, AND URETERS. 637 

Diagnosis. — Any of the above symptoms may cause the surgeon 
to suspect stone, but a definite diagnosis is impossible until a careful 
exploration of the bladder is made. This may be done in one of 
three ways — by the sound (which is the best), by digital exploration, 
or by the cystoscope. 

The same precautions should be observed in sounding for stone 
as in catheterization, as this manipulation furnishes an oppor- 
tunity for the introduction of septic material if the technique 
is not perfect. The patient should be placed in the lithotomy posi- 
tion, with the thighs flexed upon the abdomen. The vagina and 
external genitalia should be thoroughly washed with soap and water, 
then rinsed with boiled water, and then with bichloride-of-mercury 
solution (1 : 1000), and again with water. 

A piece of gauze one yard square should be spread between the 
thighs over the buttocks, and a hole made of sufficient size to per- 
mit the free manipulation of the sound. It is also well to have 
the patient's legs enveloped in sterilized stockings or towels. By 
the observance of these small details the best aseptic technique is 
obtained. The bladder should be emptied of its urine, and par- 
tially distended with boracic-acid solution or sterilized water. The 
surgeon either stands or sits between the patient's thighs when 
introducing the sound, which should previously be warmed and 
anointed with sterilized vaseline. In sounding a definite plan 
should be followed : The base of the bladder should first be care- 
fully explored, and then the sound should be caused to make excur- 
sions upward and to the sides. During this manipulation two fingers 
of the hand should be introduced into the vagina, and it will be almost 
impossible for a stone to elude the search. 

If this examination be negative and the surgeon is still in doubt, 
he may resort to the cystoscope, or the urethra can be dilated to the 
size of the index finger and a digital exploration made. In this 
way an encysted stone may be detected. In chronic cystitis or 
where vesical neoplasms exist in the walls of the bladder, or in 
the presence of a tumor encrusted with urinary salts, a peculiar 
grating sound may be elicited by contact with a metallic instru- 
ment. 

The main points of difference as elicited by the sound between 
this condition and stone is the extensive area of deposit and the 
lack of resistance when the instrument is pushed against it. The 
surgeon should always bear in mind that a calculus may be asso- 



638 AN AMERICAN TEXT-BOOK OE GYNECOLOGY. 

dated with a vesical tumor, a fragment of which has served as the- 
nucleus of the stone. 

Prognosis. — If the stone be detected early and removed before 
marked changes in the bladder have occurred, the prognosis is quite 
favorable. On the other hand, if cystitis exist associated with 
hypertrophy and contraction of the wall of the bladder, or if there 
is secondary disease of the kidneys, the prognosis is unfavorable, the 
patient dying or from the progress of the renal disease. This, how- 
ever, is very rare, as the symptoms of stone are usually so urgent as 
to lead to its detection before such grave lesions occur. 

Treatment. — There are three modes of treatment employed in 
cases of vesical calculi in women : by dilatation of the urethra and 
removal of the stone, if small, by forceps, or if large by crushing ; by 
kolpo-cystotomy ; and by suprapubic cystotomy. As the urethra 
is capable of considerable dilatation, the first method will, in a cer- 
tain number of cases, be the most available. The urethra should 
not be dilated larger than the girth of a medium-sized forefinger, 
as the sphincter fibres may be lacerated, causing permanent urin- 
ary incontinence. After the urethra has been dilated the surgeon 
introduces his finger into the bladder and locates the stone. If 
not larger than the tip of the little finger, it may be grasped with 
delicate forceps and removed, or coaxed up to the neck of the blad- 
der and out through the urethra by means of two fingers in the 
vagina. Should the stone be large, it is not advisable to remove it 
intact, as the urethra may be so overstretched that incurable incon- 
tinence will result. 

Lithotrity is usually considered the best mode of treatment when 
the stone is not too large or too dense to permit of crushing. The 
patient is placed in the same position for this operation as when 
examined for stone. The urine should be withdrawn, and the 
bladder partially distended with tepid boracic-acid solution. The 
surgeon, sitting between the patient's thighs, introduces the litho- 
trite, previously warmed and anointed with sterilized oil or vaseline, 
into the urethra in a line almost perpendicular with the long axis of 
the body. The handle of the instrument is then depressed, when it 
gently glides into the bladder. 

Two fingers of the disengaged hand should then be introduced 
into the vagina and the stone located. An assistant now opens the 
blades of the lithotrite, and with a little manipulation the stone will 
be seized, when the instrument should be very gently rotated to 






DISEASES OF URETHRA, BLADDER, AND URETERS. 639 

obviate the danger of catching the mucous membrane, and the 
screw slowly turned until the stone is crushed ; this will be sud- 
den or gradual according to its composition. The blades are then 
separated and again closed, catching one of the larger fragments, 
and so on until the stone is reduced to small particles. It is rarely 
necessary to resort to an evacuator, as repeated irrigations of the 
bladder are sufficient to remove the fragments. During the irriga- 
tions the bladder should be manipulated gently between one hand 
introduced into the vagina and the other placed above the pubes. 

Every particle of the stone should be removed, as small frag- 
ments, if left behind, may form the centres of other calculi. If the 
stone be thoroughly pulverized, there is no danger of fragments 
being impacted in the urethra. In case, however, a part of the 
stone eludes the grasp of the lithotrite and later becomes impacted, 
it may be removed by means of delicate urethral forceps, or, if lodged 
in the mouth of the urethra, it can be pushed back with a sound and 
crushed with the lithotrite. 

Urethral fever is not an infrequent complication following the in- 
troduction of instruments into the bladder, especially after lithotrity. 
It is characterized by the occurrence of rigors, with headache and 
vomiting, followed by febrile reaction. It is especially liable to 
occur in nervous women, but is not a serious complication, and 
usually passes off in one or two days. Temporary aggravation of 
the already existing cystitis may result from manipulation of the 
lithotrite. 

Contra-indications to Lithotrity. — Lithotrity should not be 
resorted to in girls under thirteen years, as the urethra is too small 
to allow sufficient manipulation of the instruments, and as lithotomy 
is such a safe operation at this age, it should always have the pref- 
erence. The size of the stones should be estimated carefully, as 
a stone of greater diameter than once inch can more easily be 
removed by kolpo-cystotomy. In those cases of sacculated bladder 
occurring in prolapsus uteri or in cystocele, lithotrity is not prac- 
tical, as small particles of the calculus are likely to be left in these 
dependent pouches. Chronic cystitis usually coexists in these cases, 
for which reason cystotomy is preferable, as we thus not only re- 
move the stone, but also secure free drainage, which will often be 
necessary to cure the accompanying inflammation of the bladder. 

If the calculus be associated with a vesical neoplasm, lithotrity 
is contra-indicated, as the manipulation of the lithotrite might induce 



640 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

a profuse hemorrhage, and the removal of the stone, if the tumor be 
left behind, would give little or no relief. 

Cystotomy is the next operative measure to be considered if 
removal of the stone through the urethra be contra-indicated. In 
women kolpo-cystotomy is almost invariably the operation of pref- 
erence, as it is comparatively easy and free from danger, and is 
applicable to the largest number of cases. This operation is best 
performed according to Emmet's method, as follows : A sharply- 
curved sound is introduced into the bladder so as to depress the 
vesico- vaginal septum. The vaginal side of the septum is then 
caught with a tenaculum and a small opening made, which may be 
enlarged with scissors by cutting upward toward the cervix, keeping 
in the median line and thus avoiding the ureters. If there is only 
a mild grade of cystitis, the fistula should be closed immediately 
after extraction of the stone ; on the other hand, should the cysti- 
tis be chronic, with considerable pus and exfoliated epithelium in 
the urine, the opening should be left, thus securing constant 
drainage. 

Suprapubic cystotomy is rarely necessary, but may be required 
in those cases in which the stone is too large to admit of vaginal 
lithotomy. Greater care is necessary in opening the abdomen of 
women than of men not to wound the peritoneum. 

The treatment after all operations for stone is simple. In those 
cases in which the fistula is left open or in which dilatation of the 
urethra is performed, the bed should be well protected with old linen, 
as there will be a constant discharge of urine. 

The parts with which the urine is liable to come in contact should 
be anointed with vaseline, and if there is any tendency to the forma- 
tion of incrusted urinary salts, the parts should be scraped gently 
and anointed with oxide-of-zinc ointment. A light diet must be 
insisted upon, and the urine kept bland by means of an abundant 
ingestion of pure water. Citrate of potash should be administered 
if the urine is acid, and benzoic acid if it is alkaline. The 
patient should return to the surgeon for examination at least once 
every year after the removal of a calculus, to ascertain if there be 
any recurrence. 

Cystitis. 
Etiology. — This is the most important question that meets us in 
the study of cystitis, and, though much important work has been 



DISEASES OF URETHRA, BLADDER, AND URETERS. 641 

done, there are many questions which are still unanswered. That the 
exciting cause of every cystitis is the presence of pathogenic organ- 
isms in the bladder is beyond question, and the first point is to deter- 
mine the various channels by which bacteria may gain an entrance 
to this viscus. 

(1) Organisms may enter the bladder through the urethra. 
That the normal urethra is the abiding-place of various organisms 
is well known, and it is easy to see how these organisms might be 
carried into the bladder by the use of even an aseptic catheter or 
other instrument. 

Again, pathogenic organisms may be carried into the bladder on 
instruments or catheters which are themselves septic. And un- 
doubtedly, in certain cases where the urethra is dilated and patulous, 
the organisms may enter the bladder directly from the urethra with- 
out using instruments. 

(2) Organisms may enter the bladder through the ureters. A 
secondary tubercular cystitis following a renal tuberculosis is a good 
example of this method of infection. There is also another variety 
of descending infection, the organisms being present in the circula- 
tion and excreted by the kidney, entering the bladder by this means 
without injuring severely the kidney itself. 

(3) Organisms may enter the bladder from inflammatory areas 
in the neighboring organs. 

This method of infection has been definitely proved, both by 
clinical cases and experimental work, and serves to explain the fre- 
quent occurrence of cystitis in women suffering with inflammatory 
diseases of the uterus, the tubes, or the ovaries. 

(4) Organisms may enter the bladder-walls through the blood- 
stream. 

This manner of entrance must also be admitted, as in no other 
way can we explain the occurrence of primary tuberculosis of the 
bladder and also the occurrence of abscesses in the bladder-wall. 

The next questions to be taken up are the predisposing causes of 
cystitis, as we know that the mere presence in the normal bladder 
of pathogenic organisms is insufficient in itself to start up a cystitis, 
and that besides the presence of the organism there are other con- 
ditions necessary. 

Some of these conditions we know, both from clinical experience 
and experimental study, but unfortunately there are still many cases 
in which the predisposing cause is entirely unknown. 



642 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

(1) Retention of the urine is undoubtedly one of the predispos- 
ing causes, and under this head may be classed the cases where 
there is prolapsus of the bladder, and therefore incomplete emp- 
tping. 

(2) The passage of irritating substances through the bladder, 
causing a congestion of the bladder-walls, under this division com- 
ing the cases of cystitis following the ingestion of irritating drugs, 
as cantharides, turpentine, etc. ; also the use of highly seasoned food 
and stimulating drinks ; and also we may class here a portion of the 
cases of cystitis following operation, the urine being irritating be- 
cause of the high specific gravity and large amount of urea and uric 
acid present. 

(3) Another predisposing cause is slight wounds of the bladder 
occasioned by the unskilful use of the catheter or other instrument ; 
and we must class here a portion of the cases of cystitis following 
operations, the bladder being wounded by the catheter. 

(4) The congestion of the bladder following inflammation of any 
of the pelvic organs is a predisposing cause, as is seen in the number 
of cases of cystitis following inflammatory conditions of the tubes, 
ovaries, or uterus. 

(5) Foreign bodies are also a cause, probably acting by wounding 
the bladder-walls, and so allowing entrance to the organisms. 

(6) New growths are also apt to be accompanied by cystitis. 
That no special organism causes inflammation of the urinary 

tract has been decided from the bacteriological study of a large 
number of cases, which prove that any pathogenic organism under 
the proper conditions may give rise to inflammation of the bladder. 

The organisms generally found are the staphylococcus pyogenes 
albus and aureus, the streptococcus pyogenes, the bacillus coli com- 
munis, several varieties of the proteus, the typhoid bacillus, the 
tubercle bacillus, and the gonococcus of Neisser. Besides these, 
many other of the less common pathogenic organisms have been 
isolated once or twice. 

The infection may be due either to the presence of a single va- 
riety of bacteria or, as is often the case, there may be several vari- 
eties present — in other words, a mixed infection. 

Forms. — Formerly all cases of cystitis were grouped under the 
head of acute and chronic, and we may still retain this division, sub- 
dividing again, however, to suit the pathological or clinical condi- 
tions present. 



DISEASES OF URETHRA, BLADDER, AND URETERS. 643 

The mildest grade of cystitis, and the one most commonly seen, 
is confined chiefly to the trigonal area and manifests itself by a 
hyperemic condition at this point. We may find a severer grade 
where the inflammation is distributed in localized patches over the 
various portions of the bladder-wall, and a still more severe grade 
is found where the whole surface of the bladder is involved. 

Diphtheritic Cystitis. — In this form, in addition to the local or 
general inflammation, there is a whitish or blood-stained membrane 
formed in various places. 

Exfoliative Qystitis. — This is quite a rare form, the severe inflam- 
mation, being accompanied by exfoliation of a part or the whole of 
the mucous membrane, and in some cases portions of the muscular 
coat are also included. 

Pathological Anatomy. — As the mild grades of cystitis never 
cause death, we are not familiar with the microscopical changes of 
this form. The macroscopic appearance as viewed through the 
cystoscope is, however, very suggestive. 

In the early stage of an acute cystitis the mucous membrane is 
red and congested, but is otherwise normal ; later the changes are 
marked, the walls of the bladder becoming thickened and the mu- 
cous surface covered with pus, fibrin, and exfoliated epithelium. 
Small bleeding areas where the epithelium has become detached are 
often seen. 

In the chronic process the pathological changes are still more 
extensive. The muscular and fibrous coats are greatly hypertrophied, 
and the actual cavity of the bladder is much decreased by the thick- 
ening and contraction of its walls. The rugae stand out as promi- 
nent ridges and may assume a polypoid form. 

Hemorrhage occurs into the mucous membrane, and appears as 
dark ecchymotic patches, which later change to slate-color as the 
extravasated blood is absorbed, leaving only the coloring matter 
in the tissues as a more or less permanent stain. 

In the severe cases of diphtheritic cystitis the membrane 
is composed not only of necrotic mucous membrane, but at times 
the muscular coat is also included. It has been stated that por- 
tions of the peritoneal covering of the bladder have been included 
in these casts. Where there is such extensive inflammation of the 
bladder the surrounding organs are more or less involved through 
extension by continuity, and are closely adherent to one another. 

In some cases the diphtheritic process becomes localized, and 



644 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

deep erosions or ragged ulcers result. These ulcerated areas may 
only involve the mucous coat, or may extend deeper and attack the 
muscular coat, and in rare instances perforate the bladder-wall. 

The urine is usually intensely alkaline and heavily laden with 
mucus and with urinary salts, especially the phosphatic. These 
salts are often deposited as fine incrustations on the ulcerated areas. 

When voided the urine may be of a reddish, brownish, or milky 
color, and if allowed to stand for a few hours in a conical glass, a 
thick yellowish or reddish sediment settles to the bottom, while the 
top is clear, or if bacteria be present it is turbid. On examining such 
a specimen microscopically there will be found a large number of leu- 
cocytes and red blood-corpuscles, pavement epithelium, isolated or 
in clumps, and often large numbers of crystals of triple phosphates. 
If the urine has undergone fermentation either within or outside the 
bladder, myriads of actively motile bacteria will be seen. 

The worst forms of diphtheritic cystitis may merge into gangrene 
and the whole bladder be involved in a putrid sloughing mass. 
Rokitansky has described a peculiar ulcer of the bladder which he 
thinks is analogous to the round ulcer of the stomach. 

As a result of the hypertrophic thickening of the bladder-walls 
the vesical orifices of the urethra may partially be occluded, and 
dilatation of the ureters, pyonephrosis, or hydronephrosis may 
occur. 

Symptoms. — In no condition is the pain more agonizing than in 
an acute or ulcerative cystitis. The pain is usually most severe 
above and behind the pubes, radiating into the groin and down the 
thighs. If able to be about, the patient walks very slowly and the 
body is slightly inclined forward ; if in bed, the legs are usually 
flexed upon the abdomen, as the slightest jar or tension of the 
abdominal muscles increases the pain. The desire to void the urine 
is constant, and the act is attended with sharp lancinating pains, 
which decrease after the urine is voided. A few drops of blood may 
be ejected with the urine. There is usually over the pubes constant 
dull pain, which increases as the bladder is distended with urine. 

Pressure over the pubes causes great pain, and at times the ten- 
derness in the region is so marked that even the weight of the bed- 
clothing cannot be borne. Following urination there is usually a 
sensation as though a few drops of urine yet remained, which gives 
rise to constant bearing-down pains. These pains may be so urgent 
as to cause the patient to remain for hours on the chamber, and may 



DISEASES OF URETHRA, BLADDER, AND URETERS. 645 

cause her to scream out with agony. There is often dull pain in 
the perineum, and occasionally a patient describes peculiar sensa- 
tions about the umbilicus. 

Increased frequency of micturition is an invariable symptom in 
cystitis, in acute cases the desire being constant ; in milder cases less 
frequent, but always urgent. 

Hematuria is frequent in the early stage of the inflammation, and 
at times there may be little else than pure blood voided. As the 
process becomes older the blood in the urine diminishes, and may 
entirely disappear. The appearance of the urine, which has been 
described above, is also characteristic. In acute or ulcerative cys- 
titis defecation may be painful and menstruation is often deranged. 
In acute cases the attack is ushered in by a rigor, followed by a 
slight increase in temperature and sharp pain in the region of the 
bladder. If of the milder type of cystitis, a few days suffice to free 
the patient from all discomfort. 

In the more severe septic or diphtheritic cases the symptoms from 
the onset indicate a very grave condition. The temperature ranges 
between 101° and 103° F. ; the rigors are severe and occur at inter- 
vals for days ; the tongue becomes dry, glazed, and coated, and may 
be fissured; there are headache and vomiting, and occasionally de- 
lirium. Micturition is difficult and excessively painful, and may be 
impossible on account of the occlusion of the ureteral orifice with 
false membrane. If the bladder is catheterized, only a small amount 
of urine can be drawn without cleansing the catheter of shreds of 
membrane. 

The bladder may become greatly distended on account of reten- 
tion. The urine has an excessively fetid odor and is of a brownish 
or reddish color. Large pieces of membrane, and at times a com- 
plete cast of the interior of the bladder, may be expelled through 
the urethra. 

The patient sinks into a typhoid state ; the pulse becomes rapid, 
running, and feeble; the temperature gradually rises during the day, 
reaching its highest point in the evening ; there may be carphologia 
and subsultus, and she finally goes into profound collapse and dies. 

As the kidneys are often much hindered in their action because 
of the vesical disorder, there may be total suppression of urine, fol- 
lowed by uremia, from which she dies. 

Diagnosis. — The dull heavy pain over the pubes, the sharp lan- 
cinating pain during micturition, and the frequent desire to void the 



646 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

urine, are all subjective symptoms strongly suggestive of cystitis. 
An examination of the urine is also of help, the recently voided 
specimen appearing turbid or blood-tinged, and on standing a thick 
whitish-yellow sediment forms at the bottom of the vessel, which 
may be pinkish in color if blood is present. 

The reaction is sometimes acid and sometimes alkaline, so nothing 
can be based on this point. If alkaline, the urine is apt to have a 
very strong fetid odor. 

The microscopical examination shows the field filled with pus- 
corpuscles singly and in clumps, red blood-cells, and pavement epi- 
thelium. 

The diagnosis can in every case be made certain by the use of 
the cystoscope. In acute cases where there is much pain and tenes- 
mus an anesthetic will be necessary. 

Prognosis. — The prognosis in the milder grades of cystitis, as in 
the cases following pregnancy or a serious operation, is usually 
good, the cystitis disappearing under appropriate treatment in a 
short time. In the severer grades the prognosis becomes more seri- 
ous, though many of these cases are finally cured. 

Chronic cystitis is always intractable, and may last for years even 
under the most skilful treatment. 

Treatment. — With our present knowledge of the causes of cys- 
titis the prophylactic treatment is of importance, and this is espe- 
cially the case in hospital practice, where patients often require 
catheterization. 

A rule should be made that every patient have a separate cath- 
eter, which is kept in an antiseptic solution and disinfected after 
each using. 

Before each catheterization the external genitals are carefully 
washed with a solution of boric acid, especial attention being paid 
to the urethral orifice. The labia are then separated with the 
thumb and fore finger of one hand, taking care not to touch the 
parts near the urethra, and the sterile catheter inserted, not allowing 
it to touch any portion of the vulva before introduction. 

The first requisite in the curative treatment of cystitis is rest, and 
to accomplish this the patient must at once go to bed and lie in the 
recumbent position. All stimulating foods, such as meats, highly- 
seasoned dishes, alcoholic beverages, especially those containing a 
large percentage of alcohol, should be avoided. It is best to restrict 
the diet to milk or light broths. Saline cathartics should be admin- 



DISEASES OF URETHRA, BLADDER, AND URETERS. 647 

istered, and later care must be used to keep the lower bowel free from 
fecal accumulation. Warm enemata are useful, not only as a means 
of evacuating the bowel, but also as a soothing agent. Hot sitz- 
baths usually relieve the tenesmus and vesical fullness. If the pain 
is severe, an enema of 30 drops of tincture of opium in 2 ounces 
of starch-water may be employed, or opium may be given in sup- 
pository. Sometimes an iodoform or belladonna suppository will 
relieve the pain. Hot compresses should be applied over the 
bladder. Cups applied to the sacrum are often useful in relieving 
tenesmus and the sensation of fullness. 

To allay the fever and keep the urine bland and unirritating the 
following prescription will prove of value: 

ty. Tinct. aconiti, f3j ; 

Spirit, aether, nitrosi, fiij ; 

Liquor potassii citratis, q. s. ad f3vj. — M. 

Sig. A dessertspoonful every four hours. 

Benzoate of ammonia, in the dose of gr. x every two hours, has 
been highly recommended. 

In acute cases which are of septic origin irrigations of the bladder 
should at once be instituted, as the removal of the infecting agent is 
of prime importance. 

The solutions used in washing out the bladder are numerous, but 
those which have been of greatest value are boracic acid (50 per 
cent, to saturated solution), weak solutions of permanganate of 
potash, bichloride of mercury (1 : 100,000, gradually increasing in 
strength), and silver nitrate (1:4 gr. to the ounce). 

The following is the best manner for irrigating the bladder : A 
glass catheter should be attached to an ordinary or fountain 
syringe by means of a rubber tubing or small soft-rubber catheter. 
The temperature of the water should be 100° to 105° F. The same 
precautions in cleansing the external genitals should be observed in 
irrigations as in catheterization. The patient lies in a recumbent 
position with the hips slightly elevated, resting on a bed-pan. The 
solution is allowed to flow before introduction of the catheter, when 
the rubber tube is pinched up, thus preventing the introduction of 
air into the bladder. A sufficient quantity of the solution is per- 
mitted to flow into the bladder until slight distension is produced 
or the patient complains of pain. The fluid is allowed to remain 
for a few seconds, when it is withdrawn by detaching the rubber 



648 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

tubing from the catheter. The irrigations should be repeated until 
the fluid flows away clear. At first the patient will probably not be 
able to stand more than one irrigation daily, but after one or two 
days she becomes accustomed to the treatment, and if the case is 
badly infected, the bladder can be washed out thrice daily. Boracic 
acid is always the best solution to commence with, as it is free from 
danger and is less irritating than bichloride of mercury or silver 
nitrate. Repeated hot vaginal douches are very beneficial. 

Where the cystitis is localized in patches the improvement 
will often be hastened by applications once in five days or once a 
week of a 3, 5, or even 10 per cent, solution of nitrate of silver, 
this application being made through the cystoscope directly upon 
the affected area. 

The treatment of chronic cystitis differs in many respects from 
that of the acute inflammation. The mucous membrane of the 
bladder, instead of being functionally over-active as in the acute 
form, is depraved and its function largely destroyed by the chronic 
inflammation. For this reason stimulating injections and internal 
remedies must be employed with the hope of bringing into activity 
the depraved mucous membrane. It is in these cases that the solu- 
tions of bichloride of mercury and silver nitrate will be of greatest 
service. More than two irrigations daily with these solutions should 
never be given. If the pain after the employment of silver nitrate 
is excessive, a 5 per cent, salt solution may be injected, which pre- 
cipitates the silver nitrate in the form of an unirritating chloride 
of silver. 

If, as in many cases, the treatment fails and the pathological 
process grows worse, it may be necessary to secure constant drain- 
age of the bladder by means of dilatation of the urethra, by vesico- 
vaginal fistula, or by the use of a self-retaining catheter. 

Dilatation of the urethra may relieve the tenesmus and secure 
drainage for a short time, but at best is but a temporary measure, 
and must be repeated a number of times if it is to be of value ; for 
this reason it is not, as a rule, practicable. It may be accomplished 
either gradually by the use of a hard-rubber graduated bougie or 
rapidly by the aid of Goodell's small uterine dilator. The danger 
of urinary incontinence must always be borne in mind, as over- 
dilatation may result in permanent incontinence. The use of a 
self-retaining catheter is only to be employed when operative 
measures are refused. 



DI8EA8ES OF URETHRA, BLADDER, AND URETERS. 649 

The best plan is drainage through a vesico-vaginal fistula. 
Emmet advises the opening to be made as follows : " The patient 
is etherized and placed in the Sims position, and the perineum well 
retracted ; a sharply-curved sound is passed into the bladder and 
its beak pressed against the septum, so as to protrude in the median 
line a short distance behind the vesical orifice : it is then cut down 
upon by the aid of tenaculum and scissors. The blunt blade of 
the latter is inserted through the opening into the bladder, and the 
incision prolonged 3 or 4 cm. in the direction of the cervix uteri. 
Care must be taken that the blade of the scissors really enters the 
bladder, since it is apt to penetrate the loose cellular tissue between 
the vesical and vaginal membranes, and thus the latter only is 
incised. The edges of the vesical and vaginal membranes should 
then be united by a continuous suture to prevent the fistula from 
closing. Any troublesome hemorrhage at the time of operation 
may at once be arrested by passing a deep transverse ligature through 
the upper or lower angle of the incision, according to the direction 
from which the blood comes ; any sucn measure will, however, 
rarely be demanded." 

The actual cautery may be used in making the fistula. After 
the opening is established the vagina should be douched at least 
twice daily with boracic-acid solution, and all parts with which 
the urine may come in contact must be anointed with cold cream or 
vaseline. 

The bladder may be irrigated as before, allowing the fluid to 
flow through the fistula into a bed-pan. As the fistula must be 
kept patulous until the cystitis is cured, which may require months, 
it will be necessary to have the patient wear some form of ambulatory 
urinal, which can be obtained at any instrument-maker's. After all 
symptoms have disappeared the fistula can be closed in the manner 
described in the article on that subject. 

Tubercular Cystitis. — Tuberculosis of the bladder is usually sec- 
ondary to renal tuberculosis, though sometimes a primary tubercu- 
losis in this organ is seen, being in such a case evidently a blood- 
infection from a primary focus in another part of the body. 

Pathological Anatomy. — As in tuberculosis elsewhere, at first 
there is the formation of minute tubercles in the mucous membrane; 
these tend to coalesce, and then, as in other parts of the body, they 
break down and form ulcers, which may be of small size or which 
may cover a large portion of the bladder- wall. 



650 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

Symptoms. — In the early stages the symptoms are those of a 
rather mild cystitis, but as the condition gets worse the symptoms 
increase markedly in severity, and will soon break the patient down 
from the constant pain and loss of rest. 

Diagnosis. — As the symptoms of tuberculosis closely simulate 
those of chronic cystitis, it is often difficult or impossible to differ- 
entiate the two conditions. In all cases of cystitis coming on 
insidiously and without apparent cause tuberculosis may be sus- 
pected, and a careful examination of the lungs should be made to^ 
discover if they are the seat of primary infection. Having excluded 
the lungs, the kidneys should be examined carefully. It is in these 
cases that the ureteral catheters are of great value. The method 
of catheterization of the ureters, as described in the article on that 
subject, should be followed. The specimens of urine obtained by 
this means should be examined for tubercle bacilli. 

The Demonstration of Tubercle Bacilli in the Urine. — The sedi- 
ment from the suspected urine is obtained from the bottom of a 
conical glass after the urine has stood for some time, or better still, 
by centrifugalization. Drops of this are spread out in a thin layer 
on several cover-slips, as in the examination of sputum, or, as the 
bacilli are often few in number and it is desirable to examine a 
large surface, some of the sediment may be spread out on an ordi- 
nary microscope slide ; after being spread the film is allowed to dry 
in the air, and the cover-glass or glass slide afterward passed quickly 
three times through the flame of a Bunsen burner or an alcohol 
lamp. Care must be taken not to overheat the specimen ; this may 
be avoided, as a rule, by holding the cover-slip between the fingers 
while passing it through the flame. 

The best method of staining for general use is that of Gabbett, 
a modification of the Ziehl-Neelson method. A few drops of the 
following solution — 



Fuchsin, pure, 


1, 


Acid, carbolic, 


5, 


Alcohol, absolute, 


10, 


Aquse destillat., 


100, 



are poured on the cover-glass, which is then held in fine forceps 
over the flame, and heated to boiling for from one-half to one 
minute; the excess of stain is washed off with water, and the 



DISEASES OF URETHRA, BLADDER, AND URETERS. 651 

cover-slip immersed for a moment or two in a combined decolor- 
izing fluid and counter-stain (sulphuric acid pure 1, distilled water 3, 
methylene blue to saturation). 

The specimen is immediately washed off in water, and if insuf- 
ficiently decolorized, again immersed in the decolorizing fluid. After 
washing in water, the cover-glass is placed between two folds of good 
filter-paper to remove the excess of water ; the glass is thoroughly 
dried high above the flame, and finally mounted in a drop of xylol 
balsam. 

A good oil-immersion lens ( T ^ or ^) is required for the examina- 
tion. Sometimes the bacilli are numerous, but in many cases there 
are very few, and it may be necessary to look carefully through many 
preparations before finding them. 

It is also necessary to warn against the possibility of confusing 
the tubercle bacillus with the smegma bacillus, which has the same 
staining qualities, and which is found in the urethra and external 
genitals. The urine to be examined should therefore always be a 
catheterized specimen, as by using the catheter the urine does not 
touch the area in which the smegma bacillus is found. 

In the early stage the cystoscope may reveal the miliary nodules 
or the localized caseous area, or later the tuberculous ulcers may 
be seen, and thus the extent of the process determined. If tubercle 
bacilli be found in the urine, and other organs are not the seat of 
primary infection, the diagnosis is definite ; but frequently a cystitis 
which seems to be the result of a localized tuberculosis will prove 
upon catheterization of the ureters to be an extension from the 
kidneys. 

Treatment. — If the infection of the bladder be primary, the 
tuberculous areas should be treated by the injection of medicated 
solutions, or the application locally of medicinal substances, as nitrate 
of silver or lactic acid. Cystotomy and curettement may some- 
times be used with good results. The bladder should be opened in 
the manner described in the article on Cystitis, and it is best to allow 
the vesical fistula to remain open, as free drainage is afforded by 
this means. Besides these local measures, the condition should be 
combated by attention to the general health, and good results often 
follow the use of creasote, and cod-liver oil, with a generous diet and, 
if possible, an open-air life. 






652 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

Tumors of the Bladder. 

Tumors of the bladder are either primary, taking origin from 
one of the layers in the bladder-wall, or secondary, the vesical 
growth being either a direct extension by contiguity from a neo- 
plasm in any of the neighboring organs, as the uterus, urethra, etc., 
or in rare instances metastasis may occur here. 

As primary tumors are the ones of importance to the surgeon, 
we will only attempt to describe this variety. 

In studying the primary tumors of the bladder, Kuester's class- 
ification, depending on the point of origin from the various layers 
composing the bladder-wall, will be followed. According to Kuester, 
the various tumors which are found in the bladder arise — 

(1) From the mucosa or submucosa ; (2) from the muscular 
coat; (3) from the epithelium. 

Tumors arising from the mucosa and submucosa are the most fre- 
quent, and are usually benign in character. 

Unfortunately, the difficulty of obtaining a clear idea of the neo- 
plasms of the bladder is much enhanced by the various names 
which have been given to the same variety of tumor. 

This is well illustrated in the number of names which have been 
bestowed upon the benign papillary growth, which is the most com- 
mon tumor seen ; for instance, Virchow spoke of the growth as a 
" fibroma papillare," Kraemer as a " papilloma," Thompson as a 
" fibro-papilloma," and Kuester as a " zotten polyp." 

This tumor histologically is made up of a branched connective- 
tissue foundation, which arises immediately from the connective tis- 
sue of the submucosa, and through which course a network of blood- 
vessels, each prolongation of the connective tissue having its ac- 
companying artery. The surface is covered by several layers of 
regularly arranged epithelial cells which are continuous with the 
epithelial covering of the bladder- wall. 

These growths usually have a pedicle which may be very short 
and broad, or may be long and rather thin ; in form they may be 
either rounded, with something the appearance of a raspberry, or, on 
the other hand, they may be of a very soft consistence, with long 
feathery prolongations. 

There is another variety of benign growth taking origin from the 
submucosa, and appearing as a rounded, rather hard growth, always 
arising by a pedicle and never showing any tendency to papillary 
excrescences. 



DISEASES OF URETHRA, BLADDER, AND URETERS. 653 

Histologically, this approaches more the type of a pure fibroma, 
the connective tissue being more or less concentrically arranged, 
and without the prolongations which are seen in the papillary 
form. 

The surface is covered by several layers of epithelial cells ar- 
ranged in order and continuous with the bladder epithelium. These 
tumors may be the seat of myxomatous degeneration, and they are 
then known as fibro-myxomas. 

Sarcoma of the bladder is one of the rarest forms of tumor seen 
here. It usually appears as a flat, fleshy growth extending over the 
bladder and infiltrating its walls, or, again, it may be found grow- 
ing from a pedicle, which is in some cases small and narrow, allow- 
ing the tumor to appear through the urethral opening. Histologi- 
cally, the tumor takes either the form of a round-celled or spindle- 
celled sarcoma, and is very rapid in its growth. 

Tumors arising from the Muscularis. — These tumors are always 
made up of bands of involuntary muscle-fibres, and of a framework 
of connective tissue, in which the blood-vessels run. They are 
usually firm in consistence, and are either pedunculated or arise 
from a flat base. They may also be multiple, though more com- 
monly only one large tumor is found. Rarely, too, instead of 
growing into the bladder-cavity, they project externally beneath 
the peritoneum, forming extra-vesical tumors. 

Tumors taking Origin from the Epithelium. — Carcinoma is the 
most common form of malignant tumor that we see, and it may 
appear either as the hard scirrhous form, extending over the sur- 
face of the bladder as slightly raised nodular growths, which 
infiltrate slowly and are of the epitheliomatous type, or of the 
softer alveolar type, these rumors projecting more into the lumen 
of the bladder and infiltrating more quickly the bladder-walls, 
and having a more marked tendency to ulceration, than the scir- 
rhous form. Both of these forms may also show a tendency to 
the formation of papillary excrescences, and undoubtedly in a cer- 
tain number of cases there is a tendency to secondary carcinoma- 
tous degeneration in the formerly benign growth. 

Adenomata have also been described, but are of very rare occur- 
rence. 

Paget has also described a case of dermoid cyst of the bladder, 
but in most of the so-called dermoid cysts the diagnosis has been 
made by the passage of hair or teeth from the bladder, these prob- 



654 AN AMERICAN TEXT-BOOK OE GYNECOLOGY. 

ably coming originally from a dermoid of some other organ which 
had ruptured secondarily into the bladder. 

Etiology. — The causes of both the benign and malignant tumors 
are unknown, save that the irritation of a prolonged or severe cys- 
titis is thought by some to be a cause of proliferative changes and 
the formation of papillary outgrowths. 

The sex of the patient has some influence, women being less apt 
to be affected by new growths of the bladder than men. 

The age also exerts influence, carcinoma being usually a disease 
of late adult life, and papillary growths are also apt to occur late 
in life, while sarcoma, on the other hand, is present at any age. 

Symptoms. — There is in every case of bladder tumor a certain 
period called the first stage, during which time there are no symp- 
toms complained of, and this has been aptly named the " latent 
period," the onset symptom marking really the beginning of the 
second stage, and not the " birth " of the tumor. 

The latent period is usually terminated abruptly by hemorrhage, 
which is most commonly the onset symptom of the second stage; 
and there seems some difference to be noted in the character of this 
hemorrhage, that accompanying the benign neoplasms usually start- 
ing without any known cause, and appearing as a few drops of blood 
at the end of micturition, or the appearance of rose-colored urine 
occasionally ; while the hemorrhage from a surface epithelioma is 
apt to follow for the first time severe exertion or a rough ride, and 
is apt to be more profuse. The hematuria in both cases is painless 
and unaccompanied by vesical irritability, and in both cases is apt 
to be intermittent. 

Another symptom is the sudden blocking of the urethra during 
micturition by the new growth and the stopping of the flow of urine, 
with straining and some vesical tenesmus. 

The onset in the rapidly infiltrating cases differs from the benign 
and the surface epitheliomata as beginning with vesical irritability, 
which is soon complicated by the presence of blood and pus in the 
urine and the symptoms of a severe cystitis. 

The later stages in both the benign and malignant cases begins 
by the appearance of cystitis, which in the benign tumors may be 
delayed for years, but when it has once begun the patient begins to 
go down hill rapidly, and, because of the liability to renal complica- 
tions, the operation for the removal of the growth has a much less 
hopeful outlook. 



DISEASES OF URETHRA, BLADDER, AND URETERS. 653 

Another symptom which when present is almost pathognomonic 
is the presence in the urine of pieces of the new growth, though 
from these pieces, unless large and retaining all of their character- 
istics, it is almost impossible to determine the variety of the growth. 

Pain in the vesical region is a very uncertain symptom, and if 
present is usually the result of cystitis. Pain has, however, been 
described as located at the external urethral orifice and in perineum 
and rectum, and not dependent on the presence of cystitis. 

Diagnosis. — The presence of intermittent painless hematuria, 
especially if complicated by the sudden stoppage of the flow of 
urine, should always excite suspicion in patients over thirty years of 
age, and a careful examination should be made to determine the seat 
and cause of the hemorrhage. 

A careful examination of the urine should be made to exclude 
renal disease, and the fresh color of the blood and its appearance at 
the end of micturition will be of help in the diagnosis. 

The direct examination by palpation is also of value, especially 
where the growth is somewhat hard and resisting. 

The bladder should be emptied, better by the patient herself than 
by the use of the catheter. Two fingers are introduced into the 
vagina, and then, with the other hand pressing directly over the 
bladder behind the symphysis, the walls of the bladder may be 
easily palpated throughout almost their whole extent by the vaginal 
fingers, which should touch carefully and slowly the whole of the 
bladder within reach. 

The use of the sound seems rather a dangerous means of exam- 
ination, and should only be attempted where other means have 
failed. 

Our most important method of diagnosis is, however, the cysto- 
scope, as by its use the whole of the bladder-wall may be visually 
examined, the character of the new growth made out, and the pos- 
sibility of operative help determined. The cystoscope should in 
these cases be used very carefully, as hemorrhage may follow any 
rough movement, obscuring the field and preventing accurate exam- 
ination. 

Treatment. — There is only one method of treating new growths 
of the bladder, and that is by operation; but there are several points 
to be decided before an operation is attempted — namely, the extent 
and character of the growth, the presence of cystitis, as this will 
lessen greatly the chances of a favorable issue, and also the general 



656 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

condition of the patient and whether she will be able to stand a 
serious operation. 

An operation having been decided on, there are three avenues by 
which the bladder may be reached : through the urethra, through 
the vagina, and through a suprapubic opening. 

The female urethra may be dilated enough to allow of the intro- 
duction of a No. 15 or 16 mm. speculum, and through this a papil- 
lary growth, if arising from a pedicle, may be removed by the snare 
or by a curette, but beyond this the urethra gives too little room to 
allow of the careful removal which is so necessary in a malignant 
growth. 

Removal through an opening made into the bladder through the 
vaginal wall is open to the same objection — want of room and in- 
ability to control perfectly the field of operation. 

The route which gives us the best chance of success, then, is the 
suprapubic, as here, if we cannot obtain all the room we want, the 
field of operation is at least directly under our eyes, and we can con- 
trol the steps of the operation much more easily. 

The patient, after having had the pubes and mons veneris care- 
fully shaved and cleaned, is placed in the Trendelenburg position. 
The incision may be either a transverse one, just above the symphysis, 
or an incision perpendicular to the symphysis in the median line. 

A male catheter is introduced into the bladder, and after the 
incision has passed through the thick subcutaneous fat, the muscular 
layers, and the prevesical fat, the bladder may be recognized by rais- 
ing it up on the end of the catheter. The bladder is then caught 
and opened, and the two free edges held by forceps or silk sutures 
which are passed through them. The neoplasm is searched for, 
being careful that no rough movements are made, as, if the growth 
is wounded before the relations are carefully studied, blood will so 
obscure the field as to make the examination and the subsequent 
operation much more difficult. If the tumor has a pedicle, this is 
divided with the scissors or a fine-pointed thermo-cautery, the hem- 
orrhage being stopped, if possible, by the use of the cautery ; or 
fine catgut ligatures may be passed under the stump. Great care 
must be exercised that in passing ligatures the ureter is not in- 
cluded, and, in fact, the relations of the ureters must be borne in 
mind during the whole operation. To bring the field of operation 
better into view, an assistant may introduce a finger or two into the 
vagi iiii and press the bladder forward. 



DISEASES OF URETHRA, BLADDER, AND URETERS. 657 

The treatment of hemorrhage is an important question, and is 
apt to give trouble. To control it the thermo-cautery may first be 
used ; if this does not do, fine catgut sutures may be passed through 
the mucosa and deeper tissues. If, however, the hemorrhage is 
severe, we cannot waste time, and it is most easily and quickly con- 
trolled by tamponing the bladder, a firm tampon being also intro- 
duced into the vagina. 

Fen wick advises operating through a " caisson " introduced through 
the suprapubic incision and pressed down over the diseased area. 
A Fergusson tubular speculum may be used in the same way. 

The bladder- wound is to be closed by a layer of fine sutures so 
introduced as not to pierce the mucous membrane. The remainder 
of the wound had best be left open, merely packing it loosely with 
gauze and allowing it to heal by granulation. If the bladder has 
been tamponed, the ends of the tampons are brought out through a 
portion of the bladder-wound left unclosed, and this tampon must 
be removed in from twenty-four to thirty-six hours, another one 
being inserted if the hemorrhage still continues. A catheter must 
be left in the bladder for the first few days. No irrigation is neces- 
sary unless there is a marked cystitis or an infection following the 
operation ; in either case the sutures in the bladder-wall will prob- 
ably break down, and the bladder must then be irrigated two or 
three times during the twenty-four hours. 

The operation which is done must be controlled by the circum- 
stances of the case — whether a beginning new growth may be cu- 
retted away or whether a piece of the bladder-wall must be excised. 
Also the removal of the whole bladder has been practised, with fairly 
good results, but every surgeon will realize what it means to undertake 
such an operation, and that unless it is carried through successfully 
the condition of the patient will be worse afterward than before. 

The palliative treatment of non-operative cases also offers the 
chance of relieving our patients of much at least -of their suffering, 
and should always be carefully attended to. The vesical tenesmus 
and constant desire to void the urine may be relieved by making a 
vesico-vaginal fistula, and daily irrigations of the bladder are use- 
ful unless they cause increased hemorrhage. The hemorrhage is a 
hard symptom to control, and in many cases all attempts are useless. 
Injections of ice-water into the bladder or the use of ice-bags over 
the pubes may be tried, as also the use of astringent injections or 
the internal administration of ergot. 

42 



I 



658 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

The pain can be relieved by the use of narcotics, opium usually 
acting well in these cases in the form of suppositories. 

Diseases of the Ureters. 

Diseases of the ureters are becoming daily of more importance 
to the surgeon as the means of diagnosis and the methods of treat- 
ment are improved. 

Anomalies of the Ureter. — As the ureter is formed by a diver- 
ticulum from the Wolffian duct, which, dividing at its free end, forms 
the calyces of the kidney, it is easy to see how, by a division taking 
place too soon, an anomalous ureter might be formed. 

The commonest anomaly seen is a partial duplication of the ure- 
ter near the renal hilus, the two tubes coalescing below to form the 
single ureter, and above at the kidney, either forming two distinct 
pelves or opening into one pelvis. A higher grade of duplication 
is seen where the two ureters, arising by separate pelves, run sep- 
arately through, side by side, nearly to the bladder before uniting. 
A complete duplication is also seen where the ureters run their entire 
course separately, one portion either entering by a blind sac in the 
bladder-wall, and thus causing a partial hydronephrosis of one kid- 
ney, or opening into the urethra or rectum ; rarely both ureters 
opening directly into the bladder by normal orifices. 

Most of these conditions are not recognized until seen at the 
autopsy table or in the dissecting-room, and therefore give rise to no 
symptoms and require no treatment. 

The cases of abnormal opening of one ureter into the vagina or 
urethra or somewhere on the vestibule give rise to annoying symp- 
toms from the constant flow from them of urine. 

Treatment. — A urinal may be worn to collect the urine and 
prevent the constant wetting of the genitals and linen, and the 
unpleasant odor which always clings to these patients ; or an ope- 
ration may be attempted, the ureter being dissected loose and turned 
into the bladder ; or a fistula may be formed between the ureter on 
one side and the bladder on the other, the edges of the two being 
sewed together with a fine needle and silk sutures. 

Trauma of the Ureter. — This subject until of recent date was 
of comparatively little importance, as so few cases occurred. Since, 
however, the recent advances in abdominal surgery the ureter is 
often wounded in removing long pelvic tumors or inflammatory 
masses, and the methods of treatment are therefore of importance. 






DISEASES OF URETHRA, BLADDER, AND URETERS. 659 

The wounds of the ureter may be divided into two classes : the 
accidental wounds and the wounds occurring during the course of 
a surgical operation. 

The first are of rare occurrence, and may either be occasioned by 
crushes or other violence, without implication of the skin and exter- 
nal coverings of the body, or they may be occasioned by a stab or a 
gunshot wound. 

Symptoms. — The subcutaneous wounds are difficult to diagnose, 
as the symptoms are very much like those of a kidney-wound, ex- 
cept there is usually no hematuria, and there is an extravasation of 
the urine into the tissues and the formation of an indistinct tumor. 

Wounds occasioned by stabbing or shooting are diagnosed by the 
direction of the wound and the effusion of urine. 

Teeatmext. — Where the diagnosis is made the treatment is 
anastomosis of the severed ends. 

Wounds of the ureter occurring during surgical operations are 
frequent, and are especially apt to be seen by the gynecological sur- 
geon, occurring during removal of large fibroid tumors of the ute- 
rus, carcinoma of the uterus, intra-ligamentary tumors, or j>elvic 
inflammatory disease. 

J Fig. 




Uretero-ureteral Anastomosis : bladder end of the ureter ligated. Stitches in place, ready for tying. 



The diagnosis is usually made by seeing the clear urine welling 
from the cut ureter. 

The wounds which may occur are divided into — (1) a simple 
wound, without complete solution of the continuity; (2) a complete 
division of the ureter, but without displacement of the extremities ; 
(3) a complete division of the ureter, with wounding of the ends. 



660 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

Treatment. — This is divided into the methods which have for 
their object a restitution of the ureter, and those by which a com- 
plete extinction of the urinary function of the affected side is in- 
tended. 

The methods of effecting the restitution of the function are dif- 
ferent, depending on the character of the wound, its position, and 
the amount of ureteral tissue which is lost. 

For instance, where the ureter is only partly cut through the 
wound may be closed by fine silk sutures, care being taken that the 
sutures do not enter the lumen. 

In cases where the ureter is cut entirely across, some method of 
anastomosis of the two ends is used. By Van Hook's method the 
lower end is closed and an incision is made in the wall of this por- 
tion of the ureter just below the closed end ; into this the upper 
end of the ureter is introduced and kept in place, partly by a catgut 
suture, which is first introduced through the upper end, and then 
both ends of the suture threaded on separate needles are carried 
through the wall of the lower end of the ureter, the needles being 
passed from within outward, and the ends tied outside. Several fine 
sutures can also be passed through the edge of the incision in the 
lower end and through a corresponding portion of the wall of the 
invaginated upper end, thus holding it more firmly in position. 

An end-to-end anastomosis has been attempted, and has been fol- 
lowed by good results, though there is a tendency to contraction of 
the scar and stricture-formation. This anastomosis may either be 
made with the two ends cut squarely across, or the two ends may be 
cut obliquely, thus giving a larger scar and lessening the danger of 
subsequent stricture. 




Bladder Implantation. Bladder end of ureter ligated : incision in bladder: stitches in place ready for 

tying. 

The sutures in these cases had best be of very fine silk and so 
introduced as not to encroach on the lumen. The method is unsafe 
in view of the certainty of success by lateral anastomosis or bladder 



DISEASES OF URETHRA, BLADDER, AND URETERS. 661 

implantation. A direct implantation of the ureter into the bladder 
has been done a number of times with success where the anastomo- 
sis method was impossible, though the uretero-ureteral anastomosis is 
the better method if it can be carried out. 

By the bladder-implantation method the bladder end of the ureter 
is ligated and dropped. The bladder is then opened at the point 
nearest to which the end of the ureter is most easily approximated. 

After freeing the ureter and opening the bladder, both ends of a 
suture (each end threaded with a separate needle) are passed through 
the wall of the ureter and brought out of the end of the vessel. 
The needles are immediately passed into the bladder through the 
opening, are made to penetrate its walls about a quarter of an inch 
from the cut margin, and are brought out upon its peritoneal surface, 
where the two ends are securely tied, thus drawing the end of the 
ureter into the bladder and there fixing it. If thought desirable, 
two such sutures may be passed. Catgut must be used for this pur- 
pose, for the reason that by its swelling it obviates any danger which 
might exist as to leakage of urine from the puncture points (which 
is exceedingly remote), and for the reason that silk might and prob- 
ably would act subsequently as a predisposing factor for the forma- 
tion of vesical calculus. 

It is probable that the sutures may draw the free end of the ure- 
ter so close to the bladder-wall as to interfere with the free flow of 
the urine ; therefore it is well to always split the ureter for a short 
distance on the side opposite to that on which the stitch is placed. 

It now remains to close the opening into the bladder. A small 
catgut suture will securely unite the cut edges of the mucous mem- 
brane of the. bladder, care being taken that it be brought snugly 
about the ureter. In fact, to the more surely secure this result a 
stitch may be carried through the wall of the ureter itself, care be- 
ing taken not to penetrate its lumen. The connective tissue, alone 
or together with the peritoneum, is now to be approximated by a 
similar suture, the same precaution as to the ureter being again 
taken. If desired, silk may be used safely for this and subsequent 
parts of the procedure. 

A ureteral fistula has also been made by implanting the cut end 
into the abdominal wound or into the vagina or rectum, but this is 
a dangerous method, and besides the annoyance of the fistula, there 
is great danger of pyonephrosis from an ascending infection. 

Complete extinction of the urinary function of the affected side 






662 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

may be effected either by ligation of the ureter or by a nephrec- 
tomy, but with the present advances in the surgery of the ureter 
the necessity for this method of dealing with a wounded ureter will 
rarely or never occur. 

Inflammation of the Ureter; Ureteritis and Periurete- 
ritis. 

Inflammation of the ureter is almost always consecutive to in- 
flammation either of the bladder or of the kidney, and may be dis- 
tinguished as ascending ureteritis or descending ureteritis as the 
infection comes from above or below. 

Another division may be made between the cases with dilatation 
and those without dilatation of the lumen of the ureteral canal. 

Etiology. — The most common variety of ureteritis is caused by 
an ascending infection from an acute or chronic cystitis. The pre- 
disposing cause, or, in other words, the reason why in some cases of 
cystitis ureteritis appears, while in others, apparently of equal sever- 
ity, ureteritis is not present, cannot be easily explained. 

Retention and stagnation of the urine in the bladder is appar- 
ently one cause, as are also the violent vesical contractions which 
accompany so many cases of cystitis, the contractions forcing the 
urine backward into the ureter. Inflammatory disease of any of 
the pelvic organs, causing pelvic congestion, is also probably a 
cause. 

The descending ureteritis is merely a direct extension of the 
inflammation of the pelvis from the kidney, and is rarer thaw the 
ascending variety. 

Pathological Anatomy. — We must differentiate between the- 
acute and the chronic forms, though clinically this is hard to do. 
The acute form shows swelling and reddening of the mucous mem- 
brane, and with the microscope there is seen to be some loss of the- 
surface epithelium, infiltration of the mucosa and submucosa with 
leucocytes, and congestion of the vessels. 

The chronic ureteritis takes two forms, according to whether 
there is dilatation or whether the tube is thickened and not dilated, 
and fixed in position by periureteral inflammation. 

The ureter in the dilated form is lengthened, tortuous, with thin 
transparent walls, looking at times like the small intestine. Under 
the microscope the walls in most places are found thin, the mucosa 
represented by either a thin line of flattened epithelium, or the epi- 



DISEASES OF URETHRA, BLADDER, AND URETERS. 663 

thelium is entirely wanting, the muscular coat being represented by 
a few fibres and the principal thickness of the wall formed by con- 
nective tissue. 

In places there are found thickenings in the wall representing 
the strictured places, the thickened spots being formed of connective 
tissue. 

In ureteritis without dilatation the ureter forms a thickened cord 
retained in place by a periureteral inflammation. The lumen in 
these cases is lessened by increase of connective tissue in the walls, 
and the elasticity has almost entirely disappeared, and in places 
there will be found strictures almost entirely destroying the lumen. 

Symptoms. — The symptoms of ureteritis are usually so overshad- 
owed by the symptoms of the accompanying disease elsewhere that 
they are not noticed. 

Pain along the course of the ureter is common, and there, is usu- 
ally tenderness on pressure in the region on each side of the umbili- 
cus, and on making a vaginal examination the ureter may be felt as 
a rounded, thickened cord in the broad ligament, where it has been 
mistaken for an ovary. 

Pyuria is also present, as is troublesome bladder tenesmus, 
and frequent desire to pass urine, though these symptoms cannot be 
spoken of as belonging to the ureteritis, they being also present in, 
pyelitis or cystitis. 

Diagnosis. — The onset of a ureteritis is usually insidious, and 
the symptoms for a time are not noticeable. The diagnosis depends 
on the character of the pain along the course of the ureter, the ten- 
derness elicited by palpation through the abdominal walls, and the 
finding of the ureter enlarged or thickened in its pelvic course by a 
vaginal examination. 

The introduction of a renal catheter will also give notice of the 
presence of strictures, both by the difficulty in passing and by the 
sudden flow of the dammed-back pus or urine after the stricture is 



Teeatment. — The most important thing in the treatment is to 
relieve the immediate cause; thus, if the patient is suffering with a 
pyelitis, the proper treatment would be drainage of the pus sac. If 
the cause is a cystitis, the cure or relief of this must be attempted ; 
the constant contractions of the irritated bladder must be lessened, 
either by using frequent irrigations or by the formation of a vesico- 
vaginal fistula. 



664 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

The local application of astringent or antiseptic fluids may be 
made immediately to the diseased mucous membrane by the use of 
the renal catheter. The ureter is catheterized in the usual way, and 
with a funnel connected to the outer end of the catheter by rubber- 
tubing the various medicinal agents, in solution, may be made to run 
into the ureter, and then, by merely lowering the funnel below the 
level of the kidney, may be siphoned out again. This is to be con- 
tinued until the urine comes away clear. 

The most useful remedies to use in this way are weak solutions 
of bichloride of mercury or nitrate of silver, the strength being 
gradually increased as the organ becomes more accustomed to the 
treatment. 

Drugs such as salol, sodium biborate, sodium salicylate, and the 
various stimulating oleo-resins may be given by mouth for their 
effect on the urinary tract during elimination, and will often be 
found useful, especially in the milder cases. 

Tuberculosis of the Ureter. — This condition, as in the ureteritis 
following infection with other pathogenic organisms, is, almost with- 
out exception, a secondary condition, though primary tubercular 
ureteritis has been described. 

The symptoms are pain along the course of the ureter, which is 
much thickened and very tender, greatly increased frequency of mic- 
turition, and in some cases the passage of blood mixed with the puru- 
lent discharge. 

The diagnosis from ureteritis following other infections can only 
be definitely decided by the examination of the purulent urine for 
tubercle bacilli, which, if found, will settle the diagnosis. 

Treatment. — As tuberculosis of the ureter is most frequently a 
secondary result of tuberculosis of the kidney, the probability that 
in most cases of tubercular kidney the ureter and pelvis of the 
kidney are also tubercular should be an indication in every nephrec- 
tomy for the removal of as much as possible of the ureter. 

Obstruction of the Ureter. 

The obstruction may be (1) by a foreign body lodged in the canal; 
(2) by changes in the wall of the ureter ; (3) by pressure exerted on 
the ureter from the outside. 

(1) Foreign Bodies Blocking the Ureteral Canal— The most im- 
portant and the most common bodies are renal calculi, which dur- 
ing their passage from the kidney become blocked somewhere along 



DISEASES OF URETHRA, BLADDER, AND URETERS. 665 

the course of the ureter. Blood-clots or clots of inspissated pus may- 
act in the same way, as may small daughter cysts in echinococcus 
disease of the kidney. 

Ureteral Calculi. — Under this head can be classed only the stones 
which remain for some time in the ureter, leaving out all cases in 
which the stone passes through the ureter, even though slowly. 
These stones are usually about the size of a cherry-pit or larger, 
and with rough, uneven edges. Stones which have been in the ure- 
ter for a longer time usually have a characteristic ovoid form from 
the additional deposit of the urinary salts on the ends ; they are 
also apt to show on one side a depression or groove through which 
the urine flows. The most common sites of impaction are just below 
the pelvis of the kidney and in the lower portion of the ureter just 
before its entrance into the bladder. More rarely they are found 
somewhere in the middle third. 

The symptoms may come on acutely, and are then described as 
occurring in the following order, namely : at first a period during 
which the patient suffers from agonizing attacks of colicky pain due 
to the passage of the stone through a portion of the ureter. This 
ends sooner or later, and the second stage comes on, the pain les- 
sening to a dull ache, and there is almost complete or a complete 
absence of the urinary flow. This absence of the urine may occur 
as a sympathetic condition where the other kidney, though healthy, 
does not secrete ; or a more dangerous condition is present where 
the other kidney is badly diseased or absent, or where there are 
stones lodged in both ureters. A fluctuating tumor may be dis- 
covered in the renal region when there is complete stoppage of one 
ureter, this being one of the causes of acute hydronephrosis. 

The symptoms may also run a chronic course, with attacks of 
dull pain somewhere along the course of the ureter, the patient often 
being able to locate exactly the seat of the pain. The urinary 
symptoms in these cases are usually absent, as, if there is complete 
cessation of the flow from one side, the other kidney will take up 
the work of both. There may, however, be seen a condition of 
" intermittent hydronephrosis " on the affected side, the stone being 
capable of some motion and acting as a ball valve. 

Diagnosis. — In the more acute cases the diagnosis is usually not 
difficult, as the history of an acute attack of pain, the dull pain 
located somewhere along the course of the ureter, and the partial or 
complete cessation of the urinary flow, all point to the condition 



666 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

present. More important, however, is the condition of the other 
kidney, this only being determined by careful study of the indi- 
vidual case. The use of the renal catheter will be of great help in 
these cases, and by coating the tip lightly with dental wax the 
scratch-marks occasioned by contact with the stone can be seen. 

In the cases where the onset is more insidious and the course 
chronic the diagnosis is difficult, especially if there is complete ob- 
struction and no urine can pass the stone. 

Here the diagnosis must rest on the previous history of renal 
colic, the dull aching pain localized usually in one spot, and the 
intermittent hydronephrosis which is present in some cases. The 
use of the renal catheter in these cases will give valuable results. 

Treatment. — A stone having been diagnosed, the only method 
of treatment is the removal by operation, though diuretics and 
abdominal massage, with the hope of pushing the stone into the 
bladder, have been advised. 

Two methods of reaching the ureter are open to us — namely, 
the transperitoneal and the extraperitoneal routes, and a third 
method, if the stone lies near the bladder, is through a vaginal 
opening. 

The transperitoneal route allows the ureter to be examined more 
fully through a shorter incision, and the other kidney and ureter 
can be examined and the condition noted at the same time ; but this 
method is more dangerous, unless the urine above the stone is per- 
fectly aseptic, from the septic urine entering the peritoneal cavity. 

If the transperitoneal route is chosen, the incision can be made 
either in the median line or external to this along the external 
border of the rectus. 

In opening the ureter a longitudinal incision should be made, 
and after the stone is removed the incision is closed tightly with fine 
silk or catgut, the sutures being so introduced as not to enter the 
lumen of the canal. 

The extraperitoneal route is safer, though it involves a longer 
incision, and it is sometimes difficult to find the ureter. The incis- 
ion begins in the lumbar region just below the twelfth rib and 
about at the edge of the quadratus muscle, and from here a line is 
followed curving around the side of the abdomen, just above the 
iliac crest, to the anterior superior spine. The hilus of the kidney 
is first located, then the ureter, and by putting this slightly on the 
stretch it can be traced to where it enters the pelvis, and with the 



DISEASES OF URETHRA, BLADDER, AND URETERS. 667 

hand in the wound can be followed in its course until the broad 
ligament is reached. The method of opening and the closing of the 
ureter are the same here as in the transperitoneal method. 

(2) Changes in the Wall of the Ureter causing Obstruction. — 
The most common changes seen here are the strictures of the ureter 
following inflammatory changes in its walls. These strictures may- 
be single or multiple, and may be situated in any portion of the 
ureter. 

The most common site is, however, near the ureteral opening into 
the bladder, and next to this the most common site for the stricture 
is near the junction of the ureter and pelvis of the kidney. The 
small cysts and the polypoid tumors are uncommon causes of ob- 
struction. 

Symptoms. — In many of the cases the obstruction will give rise 
to no symptoms, this being especially true for the non-infected cases, 
though the symptoms of hydronephrosis from the slow accumulation 

Fig. 340. 




Catheterization of both Ureters: Left-hand glass showing greatest quantity of urine secreted during a 
given interval ; urine clear. Right-hand glass showing a much smaller quantity of urine secreted ; 
urine bloody, indicating the diseased kidney and the character of the disease. 



of urine may be present. If the case is a septic one and the pus is 
prevented by the obstruction from emptying itself, there will be a 
history of pain, rise of temperature, and all the symptoms of puru- 
lent retention, with the presence in the flank of a tumor tender on 
pressure and slowly increasing in size. 

Diagnosis. — In the slow, insidious non-infected cases the only 
means of diagnosis is the renal catheter, by the use of which we can 



668 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

locate the stricture, introducing it slowly and noting when there is a 
sudden outflow of urine, indicating that the stricture is passed. The 
amount of urine which is then collected should be saved, as indicat- 
ing the amount of retention. In the infected cases the diagnosis 
will not be so difficult, the history of the patient, the presence of the 
tumor, and the pus withdrawn by the catheter, all showing the 
nature of the lesion. 

Treatment. — A stricture low down near the ureteral orifice 
can be dilated by the use of a metal catheter, the size of the one 
used being slowly increased, or metal bougies may be used in the 
same way. 

A stricture in the middle portion of the ureter may be dilated in 
the same manner by using the flexible-silk renal catheters. Stric- 
tures or kinks in the ureter near the pelvis of the kidney have 
been relieved by operation, either excising the strictured portion 
and performing a uretero-ureteral anastomosis or by a plastic opera- 
tion. In the purulent cases the accumulation of pus must be re- 
moved and the inflammation combated in addition to the dilatation 
of the stricture. 

(3) Obstruction of the Ureter by Pressure from the Outside. — 
In women the most common cause of obstruction is from new 
growths or inflammation of the genital tract, there being, for ex- 
ample, in carcinoma of the uterus with extension laterally a large 
percentage of cases where there is almost complete obstruction to 
the outflow of urine, many of the patients suffering with carcinoma 
of the uterus dying from uremia. The ureter may also be blocked 
by pressure from a band of adhesion crossing it, and there are cases 
described where a congenitally misplaced vessel crosses and obstructs 
the ureter. 

Symptoms. — These cases, unless there is infection and very marked 
symptoms, are usually entirely obscured by the accompanying dis- 
ease, not being discovered until either an operation is attempted 
for the pelvic disease or the patient dies and comes to the autopsy 
table. 

Treatment. — As the cause is external to the ureter, the only 
method of treatment is by removal of this cause. Carcinoma which 
has developed enough to exert pressure is usually hopeless, and the 
only method of treatment is either by an operation to implant the 
ureters into the vagina or rectum or bring them out of the abdomen 
through an abdominal wound. As this will prolong life but a few 



DISEASES OF URETHRA, BLADDER, AND URETERS. 669 

months, and is attended by all the discomforts of urinary fistula, in 
most cases at least it would seem to be contraindicated. Where the 
pressure is exerted by a pelvic abscess, severe pelvic adhesions, or 
by a large myoma, operation and the removal of the cause will 
relieve the ureteral condition. 

New Growths of the Ureter. 

Primary growths of the ureter are very rare, with the exception 
of the small polypoid tumors which are occasionally found in the 
pelvis of the kidney and upper portion of the ureter, and which 
usually give rise to no symptoms, though if they are large there 
may be hemorrhage from them, simulating a malignant growth of 
the kidney. 

One case of sarcoma of the ureter has been reported which was 
operated on for a renal tumor. 

Small cysts of the ureter are not uncommon, and are supposed 
by some to be the result of a folding in and adhesion of the mucous 
membrane following inflammation ; by others they are considered 
to be due to the presence here of a sporozoa. They give rise to no 
symptoms, and are only of pathological interest. 

Secondary new growths of the ureter are not so uncommon, they 
either extending from a renal tumor, or in the lower portion the 
ureter may be affected from a primary growth in the bladder or the 
genital org-ans. 



AFTER-TREATMENT IN GYNECOLOGICAL OPERATIONS. 



Abdominal and Vaginal Section. 

The importance of this whole subject is realized by every sur- 
geon engaged in the practice of gynecological operations, and the 
want of some convenient literature to which reference may be made 
has often been deplored. 

There are certain well-defined principles which may be followed 
in conducting the after-treatment of a patient upon whom an abdom- 
inal section has been performed, but concerning the details of any 
given case, the surgeon must be governed in great measure by the 
conditions as they arise. These conditions may best be met and 
overcome by carrying out the principles to be enunciated, and by 
deviating from them only when an emergency arises; even then 
keeping well in view the general objects to be obtained. 

Best. — When the patient leaves the operating table rest is to be 
the first consideration — rest for the body, rest for the mind ; the lat- 
ter can only be attained simultaneously with the first. The woman 
should be placed upon her back, and kept in that position for the 
first few days or until her bowels have been moved. If a drainage- 
tube, especially a glass one, has been employed, she must remain in 
this position until it is removed. While upon her back the knees 
may be drawn up or the legs extended, as is most comfortable for 
her. She will frequently desire a change of their position, which 
should always be made by the nurse. While the knees are drawn 
up they are to be supported by a pillow inserted under them, so as 
to remove the strain incident upon the muscular effort necessary 
to keep them in position if left to themselves. It is never to be 
forgotten that when a patient lies for a considerable length of 
time in any one position every crease or wrinkle in the bed-linen 
becomes a source of annoyance, if not of great discomfort. The 
woman is intensely uncomfortable, and is suffering considerably 
from pain at the best : every possible added source of discom- 



AFTER-TREATMENT IN GYNECOLOGICAL OPERATIONS. 671 

fort must be removed. She is sure to suffer a greal deal of pain 
and distress as the result of her operation, and if kept on her 
back she naturally attributes all the trouble to the position, when 
in reality it is not so. It should be one of the chief objects of 
the nurse from the first to keep both the bed-gown and the sheets 
under the patient's back perfectly smooth. A woman will beg hard 
to be allowed to turn, if only for a moment, when, if her clothing and 
the bed-sheets are smoothed out and her pillows shaken up, she will 
be rendered fairly comfortable, and will remain so for a consider- 
able length of time. This absolute rest upon the back is desirable 
for a number of reasons : If she is allowed a little liberty, she will 
toss and turn about, hoping to find relief first in one position, then 
in another, only to fail ; but in the meanwhile a ligature which has 
been loosely placed or which encircles an especially large pedicle 
is unable to withstand the tension it is placed under, and bleeding 
begins — possibly only slight in amount, but it may be sufficient to 
kill. When a drainage-tube is used, if made of glass, it is very 
likely to become broken, and if of any other material, displaced. 
The stomach, which is already irritable, becomes worse, and the 
vomiting is not so quickly controlled. Every movement causes 
the patient pain, and if the edges of the abdominal wound are not 
closely coapted, they are apt to become displaced, as are also the 
dressings. The pulse is always more steady with the patient in the 
■dorsal position. 

Vomiting. — Rest must not only be obtained for the body but 
also for the stomach. The anesthetic has rendered that organ 
so irritable that the slightest disturbance causes it to reject 
anything it may contain. The retching and vomiting follow- 
ing abdominal section are exaggerated over and above that from 
simple anesthesia. The symptom is to be treated by rest, pure and 
simple. Under any circumstances the organ will remain irritable 
until the effect of the anesthetic has worn away, and drugs will not 
improve its condition materially : it will be extremely fortunate if 
they do not render it worse. The treatment of the vomiting con- 
sists in allowing the stomach to remain quiet. This is best accom- 
plished by withholding drugs, stimulants, food, or water. Abso- 
lutely nothing should be allowed to pass the patient's lips until the 
vomiting has ceased, which will generally be within from twelve to 
twenty hours. Should it be necessary to administer nourishment 
{luring this time, rectal enemata may be used ; however, the patient 



672 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

usually does very well without either nourishment or stimulants 
for several days. 

Drink. — It is well to withhold fluids until the vomiting has 
entirely ceased, and then to administer them only in small quantities. 
They should be begun by allowing a small spoonful of hydrant- or 
soda-water every fifteen minutes, testing the ability of the stomach to 
retain and absorb it, and gradually increasing the quantity until 
within twelve hours the patient is taking an ounce each hour. The 
mouth may be moistened and cleansed during the interval of vom- 
iting immediately succeeding the operation, by the aid of a wet cloth 
on the finger of the nurse. Should the thirst become intolerable 
during this period, it may be relieved by administering an enema 
of two or three ounces of hot water at intervals of four hours.. 
The habit of giving ice by the mouth is bad and should be 
avoided. The cold water accumulates in the already over-irritated 
stomach, which is in no condition to absorb, until finally it 
is rejected, in the meanwhile having rendered the patient more 
uncomfortable. The intense thirst created by the withholding of 
drink is a great desideratum, as the blood-vessels, being unable to 
satisfy their demand for fluids from the stomach, draw upon the 
serum and blood which have accumulated in the pelvis. An 
amount of septic matter of which the peritoneum might readily 
dispose may cause a septic peritonitis and death if it can find so 
favorable a medium in which to develop as is afforded by this 
accumulated bloody serum. 

Food. — For the same reason that it is unwise to give drink it is 
best to withhold food. The stomach will not retain it until it has 
recovered from the irritation of the ether : even should food be 
retained, it will accumulate and remain unabsorbed, the added 
irritation of its presence causing an excessive pouring-out of gastric 
juice and considerable discomfort to the patient. In addition, 
purgatives will not act so readily when administered together with 
food, and it is desirable to have the bowels move as soon after an 
operation as possible. If food lay on the stomach for any length 
of time, decomposition sets in and flatulence is induced. Food may 
safely be withheld for forty-eight hours excepting in unusual cases, 
when, if it be required, it may be given in the form of enemata ; 
stimulants may be administered in the same manner when indicated. 
When the stomach has shown itself thoroughly tolerant to drink, 
it is then time to begin to offer the patient fluid nourishment. 



AFTER-TREATMENT IN GYNECOLOGICAL OPERATIONS. 673 

Buttermilk is most acceptable to the majority of women. It 
should be given in small quantities often repeated, half an ounce 
every hour or two, testing the capability of the stomach to retain 
and digest it. It is not wise to attempt too much in the way of 
feeding until the purgatives have gotten well under way. Milk, 
unless predigested, is not a good food for this class of patients ; it 
almost invariably causes the formation of flatus. Beef-tea or beef- 
extracts may be alternated with the buttermilk. Soups or broths 
of any kind may be substituted as the patient tires of one or the 
other. In fact, any article of soft diet which is suitable for the 
sick-room may be of service, the greater the variety the better. 
As soon as the bowels have been opened, usually in about forty- 
eight hours, the patient's appetite begins to assert itself, and where 
before she took what was offered her under protest, she will now 
begin to enjoy what she is given. It is at this time perfectly safe 
to consult her appetite ; anything that she fancies may be given 
her. As a matter of fact, for the first four days after the operation 
she will want little but soft or semi-soft food, but if after the bowels 
are opened she wishes solid food, it can do no harm to allow her 
to have it. She has been starved for three or four days ; now feed 
her generously. There are exceptions to this, but they will be 
noted in their proper places. 

Purgatives. — It is imperative to obtain a movement of the bowels 
at as early' a date after operation as possible. The condition of the 
bowels and pulse is the surest indication of the progress of the 
patient. If at the end of forty-eight or sixty hours a good and 
satisfactory movement of the bowels has been obtained, and the 
pulse be below 100 beats to the minute, the patient is convalescent. 
If, on the other hand, the bowels remain unmoved in spite of all 
efforts to open them, tympany begins to appear, and the pulse 
slowly rises to the neighborhood of 120 beats to the minute or 
higher, it is a serious matter for the patient. The one hope under 
these circumstances is to get the intestinal canal open, and it is at 
times astounding to note the great change for the better which takes 
place when this has been satisfactorily accomplished. The distress 
incident to the distension will have disappeared, the vomiting will 
have ceased, the pulse will have dropped to the neighborhood of nor- 
mal, the anxious expression of the face will have cleared away, and 
the patient will look and express herself as feeling very much better 
in all respects. The alteration is that of complete change from an 



674 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

appearance and condition of extreme distress and suffering to one 
of absolute contentment and comfort. Twenty-four hours after 
the operation, or as soon as the vomiting has ceased, calomel in 
half-grain doses, to be repeated each hour, should be given until 
ten or twelve doses have been taken : this should be followed by a 
Seidlitz powder or a tablespoonful of Kochelle or Epsom salts, dis- 
solved in a small quantity of water, every two hours until the desired 
effect is accomplished. As soon as the bowels begin to rumble, flatus 
is passed, or the saline is rejected a large enema of hot soapsuds, a 
quart or more, containing a tablespoonful of turpentine, should be 
given : the enema may be repeated at intervals of three or four hours 
if necessary. Calomel will be retained upon the stomach when 
everything else is rejected, but there must be a limit to the adminis- 
tration of this drug, else the patient will become salivated. A stom- 
ach which is ejecting everything will at times become settled when 
the calomel is begun. If the magnesia salts are not retained, some 
other form of drug will have to be used, such as compound licorice 
powder, or, in desperate cases, even croton oil. When the bowels 
have not responded to treatment by the end of the third day after 
operation and the pulse has gradually risen to 130 beats or more, it 
is the exceptional case which recovers : such patients are generally 
dead by the end of the fourth day. Efforts to obtain the desired 
result should not cease until the case is clearly hopeless. If the 
bowels do respond, even apparently desperate cases at times rally 
quickly, and are convalescent in a few hours. The depletion of 
the blood-vessels incident to the purgation is another factor in caus- 
ing the absorption of the bloody serum in the peritoneal cavity, and 
for this reason, if for no other, it is desirable to secure a number of 
watery stools. Subsequently a daily movement should be secured. 

Should any of the intestines become injured during the course 
of the operation and there is danger of fecal extravasation, absolute 
rest must be obtained for the bowels until such time as Nature may 
protect the dangerous point with peritoneal lymph and adhesions. 
Under these circumstances morphia may be administered hypoder- 
matically in quarter-grain doses repeated sufficiently often to keep 
the intestines quiet. Three or four doses in the twenty-four hours 
will answer the purpose : opium suppositories of one grain each, 
repeated at intervals of six or eight hours, would answer just as well. 
The opiate, in addition to helping to inhibit the peristaltic action of 
the intestines and tending to prevent the natural secretions in the 



AFTER-TREATMENT IN GYNECOLOGICAL OPERATIONS. 675 

gut, allays the irritability of the stomach and prevents retching or 
vomiting until such time as the adhesions and lymph have become 
strong enough to offer the necessary resistance. Should vomiting 
occur during the first few days, almost certainly the intestinal con- 
tents will be forced through the light barrier formed by the lymph 
and into the pelvic and abdominal cavity. No effort should be made 
to move the bowels for at least four days after operation, when 
small doses of magnesium sulphate or castor oil may be adminis- 
tered, followed by an enema of soap and hot water as soon as the 
patient feels a tendency for the bowels to move. Great care should 
always be observed in such cases in giving the enema that the 
bowels be not over-distended, else irreparable damage may result. 
If the injury has been to the small intestine, it will have been re- 
paired with stitches at the time of the operation, and little differ- 
ence need be observed in the after-treatment except that purgatives 
should not be begun until the end of the second or third day. Not 
much harm can occur from an injury so high up if properly repaired. 
Where the damage is to the sigmoid flexure of the colon or to 
the rectum, as is most generally the case, it is so low down in the 
pelvis that the sutures cannot be placed satisfactorily or safely, and 
unless great care is observed, irretrievable damage may be done 
when the bowels are allowed to open. It is not a good plan to 
f How the intestine to remain quiescent for too long a time, else the 
colon and rectum will become filled with scybalous masses which 
may prevent closure of a laceration or may tear it open after it is 
partially healed. When the bowels have once moved they should 
be opened daily, if not acting naturally, by a laxative or an enema. 
Bladder. — Should it become necessary, the urine may be with- 
drawn with the aid of a catheter. It is only, however, when abso- 
lutely necessary that the catheter should be used. If a proper 
length of time is allowed to lapse after the operation, most 
patients will void their own urine, and, having once done so, there 
will be no further necessity for the use of the instrument. If the 
bladder is once relieved artificially, it is most likely that it will 
be again demanded by the patient, and if the temptation be yielded 
to a few times, it will be difficult to break the habit. It is best, 
if possible, to force the patient to pass her own urine from the 
start, and if she is watched carefully for any untoward symptoms, 
the urine may be allowed to accumulate for from fifteen to twenty 
hours if necessary, the patient being offered the bed-pan occasionally 



676 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

during this interval, and every effort being made to aid her in her 
endeavors to accomplish the act of urination. A small stream of 
warm water squeezed from a sponge, if allowed to run down over 
the meatus at times, accomplishes the result. When the catheter is 
used, the greatest care should be taken that the bladder be not in- 
fected. The instrument should be preferably a soft-rubber one, 
and should be antiseptically clean. It should have been prepared 
by being immersed in boiling water, washed in a bichloride-of- 
mercury or carbolic-acid solution, and kept in alcohol until needed. 
It should never be used without fully exposing the parts. The 
patient's knees being well drawn up and separated, the labia are 
drawn apart with the finger of one hand and the meatus exposed 
to view. The parts are thoroughly cleansed with a piece of cotton 
wet with a carbolic-acid or bichloride-of-mercury solution, and the 
point of the catheter introduced directly into the meatus without 
being allowed to come in contact with any of the contiguous parts. 
Thus, and only thus, can the patient's bladder be ensured against 
infection. A cystitis at this stage of the convalescence will often 
give rise to serious symptoms and an immense deal of discomfort, to 
say nothing of danger to the patient. 

If during the operation the bladder has been injured or torn 
open, whether it has been sutured or not, the after-management of 
the urine must differ somewhat from that which is usual. If under 
these circumstances the organ is allowed to become distended, 
there is apt to be leakage at the point of injury between the 
sutures, or if only the outer coats of its walls have been torn away 
in separating adhesions, a rupture might readily occur at this 
point were the urine not removed for fifteen or twenty hours. It 
should always be arranged in case of such injuries that there be no 
accumulation allowed. A soft-rubber catheter may be left in the 
bladder permanently, by means of which the contents can be con- 
veyed into a vessel over the side of the bed, through a long piece 
of drainage tubing attached to the end of the catheter ; or, better 
still, a self-retaining female catheter may be utilized for this pur- 
pose. Three or four days will be sufficient for its use, after which 
the patient may be catheterized five or six times in the twenty-four 
hours, the use of the instrument becoming gradually less frequent, 
until in a week or ten days it may be omitted altogether. If dur- 
ing the convalescence cystitis should develop, it becomes necessary 
to treat it promptly. A careful inspection of the methods of cathe- 



AFTER-TREATMENT IN GYNECOLOGICAL OPERATIONS. 677 

terization should be made, and rectified if found faulty. The vast 
majority of cases of cystitis arise from this source. Diuretics should 
be administered freely, provided the stomach has reached the state 
when it can bear them. 

If the cystitis develops within the first day or two, before 
the bowels are thoroughly opened, internal medication is better 
withheld for the time and local treatment depended upon. In 
any event, most reliance must be placed upon the local man- 
agement, irrigating the bladder twice daily with a mild anti- 
septic solution and seeing to it that no residual urine remains to 
undergo decomposition. A warm solution of permanganate of 
potash, not sufficiently strong to cause burning, may be passed 
into the bladder until the patient complains of the distress. This is 
accomplished by the aid of a soft-rubber catheter with a piece of long 
rubber tubing attached, terminating at the opposite end in a small 
funnel. The funnel is elevated, and the fluid allowed to enter the 
bladder through the introduced catheter, by the force of gravity. 
As soon as the woman complains of much pain, the funnel may be 
depressed into a vessel resting on the floor, and the solution allowed 
to siphon away. The action of the residual urine will have decom- 
posed the permanganate of potash in the solution, and it will return 
almost the color of ordinary water. It is then necessary to refill 
the bladder without withdrawing the catheter, with a fresh solution, 
in order that the unaltered drug may come in contact with the in- 
flamed and suppurating walls. After a few washings the patient 
will become more comfortable and the cure will be accomplished 
quickly. The urine in the mean while must be rendered as nearly 
neutral as possible. 

If there is preexisting kidney disease, symptoms of uremia may 
develop after the operation. The quantity of urine voided should 
be carefully noted and this symptom anticipated : following the ope- 
ration, the quantity of urine secreted during the first few days is 
always small, often not more than eight or ten ounces during the 
first twenty-four hours, but increasing rapidly in amount with each 
succeeding day : due allowance must be made for this. The treat- 
ment of this complication will be similar to that of uremia under 
any other circumstances. If it once develops, the patient is usually 
lost, although an occasional case is saved by prompt action. Purga- 
tion, diuretics, diaphoretics, heat, and local bleeding are all indicated, 
and must be applied promptly if any good is to be derived from them. 



678 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

Croton oil for purgation, cocaine and digitalis for diuresis, leeches 
and cupping over the kidneys for bleeding, and dry heat applied 
about the parts, are the chief remedies to meet the indications. 

Bathing. — Bathing is an important element in the comfort of an 
operative case, and should be begun as soon after operation as pos- 
sible. The bowels will, in a normal case, be opened by the end of 
forty-eight or sixty hours. As soon after this as the patient has had 
time to rest a while and regain a slight amount of strength, there 
being always a period of a few hours of weakness after the purga- 
tion, a warm sponge-bath may safely be given. The end of the 
third twenty-four hours is about the usual time for this first general 
bath : from the very first the hands, arms, neck, face, and legs should 
have been frequently bathed. From this time a daily sponge-bath 
of warm water, followed by alcohol, is to be given. The amount of 
comfort derived from this procedure is indescribable, and, if due care 
be taken not to chill the patient, not the slightest harm can come of 
it. The hair and teeth should receive attention from the very first. 

Flatulence. — This symptom is the most distressing one met with 
in the after-treatment of abdominal surgery. It accompanies, more 
or less, all cases, although in a very great many the amount is so 
slight that it is hardly noticed and requires no special attention. 
Where the woman's life is seriously threatened and she is eventually 
going to die, it is usually at its worst, and practically nothing can 
be done for its relief. 

Flatulence itself is capable of killing, and almost to the last 
it is impossible to say whether or not there is a chance of 
saving the patient : for this reason there should be no cessation 
in the efforts for its dissipation. Usually it does not appear 
for from twelve to twenty-four hours, and in the majority of 
cases, where the bowels are opened at the end of forty-eight 
hours, it is permanently relieved. This being true, the great effort 
for its relief should be in the direction of securing a movement of 
the bowels. That form of flatulence which appears within twelve 
hours after the operation is usually easily dealt with, and in itself 
has no great significance and need give no particular alarm. It is 
the variety which begins to show itself toward the end of the 
second twenty-four hours, which is accompanied with a refusal of 
the bowels to move, together with a quickening and weak pulse, 
which is to be dreaded : it most frequently means septic peritonitis 
and death. Little in the way of drugs, excepting purgatives, is 



AFTER-TREATMENT IN GYNECOLOGICAL OPERATIONS. 679 

worth administering. Large rectal enemata of water and turpen- 
tine, and the rectal tube introduced and at times allowed to remain 
in situ, will in some cases give relief. This is not very great, how- 
ever, and the practice has more theoretical than practical value. 
Puncturing the intestines through the abdominal wall is never 
justifiable : if it is thought desirable to attempt to relieve the disten- 
sion by this source, a small incision should be made in the abdom- 
inal wall, a knuckle of gut caught up, opened, and either stitched 
to the abdominal wall or else closed by a few sutures when the 
opening has accomplished its object. The same thing might readily 
be done through the original incision by removing a stitch or two 
and separating the edges of the wound quickly with a finger. The 
whole procedure can be carried out with the patient lying in bed and 
without an anesthetic. It is rare that anything can be hoped for 
from this direction, however, and it is seldom worth considering. 
Usually the result would be that only a single coil of intestine 
would be emptied, and nothing particular would be accomplished. 
The stomach-pump is a valuable aid in some of these cases, 
especially where the distension appears quite prominent in the 
epigastric region. Large quantities of fluids and air may be 
occasionally removed by its aid, and the distressed expression on 
a patient's face will clear up almost instantly after its successful 
use. Where it succeeds at all, after the first application the patient 
will in a few hours beg for a repetition, so great has been the relief 
obtained. 

As a matter of fact, unless the bowels can be gotten to move we 
can do little to permanently relieve this symptom, and even in those 
cases of sepsis in which the bowels have responded to the purgatives 
and enemata in a more or less satisfactory manner, the relief from 
the flatulence is not great, nor is it permanent, returning in a few 
hours with the bowels obstinately constipated. At times, when 
nothing else will answer the purpose, turning the patient on the 
side will bring about the desired result. 

The causes of flatulence are varied. Too early administration 
of food where the stomach is so irritable that it does not perform 
its function of digestion and absorption, is a common cause. Milk, 
especially, of all foods is most likely to favor its formation. 

It invariably accompanies sepsis, in which case it is most stubborn. 
Handling the intestines during the operation is supposed to be 
a common cause, but at times it follows, in cases where the 



680 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

intestines have not been seen or have been handled a minimum 
amount : at other times when there has been partial evisceration 
and severe handling, even to the placing of stitches in the intestitnal 
walls, there is no flatulence following the procedure. The real cause 
of flatulence is unknown, and its treatment is most unsatisfactory, 
except where the bowels can be gotten to move, when, as a rule, 
it disappears. Occasionally, however, where daily free evacuations 
of the bowels are taking place, a distressing amount of flatus may 
remain for days. 

Drainage-tube. — The care of the drainage-tube is one of the most 
important parts of the after-treatment. Should the tube be made 
of glass, each time it is cleaned the nurse or physician is practically 
dealing with an open wound, and just as great care should be mani- 
fested in its cleansing as is done at the operation itself: for the first 
few days the danger of infection is just as great. Should the tube- 
track become infected at this time, the chances are largely in favor 
of a septic peritonitis and death ; if the infection takes place later, 
when Nature has thrown out enough lymph to protect the perito- 
neal cavity, a suppurating pelvis with, possibly, a more or less 
permanent fistula, may be the first result. Under any cir- 
cumstances infection is dangerous : if it does not end in death, it 
generally terminates in a fistula, which is more or less stubborn in 
healing. In cleaning a glass drainage-tube it is necessary to pass a 
long-nozzled syringe to the bottom of the tube in order to suck 
up the serum and blood which have accumulated in the pelvis. 
The syringe itself may be infected and carry the poison into the 
pelvis, or it may become infected as it passes the mouth of the 
tube. At each tube-cleaning the hands should be well washed 
with soap and water and disinfected with a bichloride-of-mercury 
solution. Clean towels should be placed about the tube, and the 
dressings over its mouth removed, so as to expose the open- 
ing. The syringe should be immersed in boiling water and 
the barrel filled and refilled several times ; it is then to be filled 
and refilled several times with a bichloride-of-mercury solution 
(1 : 1000) ; from this solution it is to be passed again into hot water 
and the mercurial washed away, when it is ready for use. The point 
of the syringe is passed to the bottom of the tube, and then with- 
drawn about a quarter or half an inch, so that when the piston is 
drawn the fluids in the pelvis will be sucked up, but not the tissue 
of the pelvis. If any clots or shreds of tissue remain in the pel- 



AFTER-TREATMENT IN GYNECOLOGICAL OPERATIONS. 681 

vis, the suction will draw them to the mouth of the nozzle, when by 
keeping up the suction they may be readily withdrawn. The syringe 
is to be used until the tube is perfectly dry. After using the syringe, 
it is to be first washed out thoroughly with hot water until the 
flow comes away perfectly clear and unstained, then the bichlo- 
ride-of-mercury solution is to be repeatedly drawn into it, and the 
syringe put away wet with the solution. It is to be placed imme- 
diately upon a clean towel kept for that purpose, and folded up so 
as to remain unexposed until again required. Each time the tube 
is cleaned its mouth is to be well washed with a piece of cotton wet 
with a bichloride-of-mercury solution, and the wet cotton is to be 
passed down the tube as far as possible (an inch), so as to render its 
caliber thoroughly clean. The rubber-dam about the tube should be 
carefully cleansed of any drops of blood or serum which may have 
soiled it, and clean cotton is placed over the mouth of the tube. 
All this trouble may seem unnecessary, but any one familiar with 
the dangers of sepsis will appreciate its importance. A drop of 
blood or serum left about the mouth of the tube or in the syringe 
will quickly undergo decomposition. It is much easier to prevent 
sepsis than to cure it. 

Each time the tube is cleansed it should be twisted back and 
forth several times. The lymph which is thrown about the tube, 
penetrates the small perforations at its bottom, and if not broken 
up, and kept so by frequent rotation, becomes firm enough to cause 
considerable difficulty in the subsequent removal. This difficulty 
has been such a common one that several instruments have been 
devised for the express purpose of cutting the tube loose. If the 
simjDle precaution be observed of twisting the tube back and forth 
at each dressing, no such difficulty will ever arise. 

The drainage-tube should be allowed to remain in situ until 
such time as it is no longer needed for drainage. This time varies 
in different cases, and no hard-and-fast rule can be laid down 
for all. A few drachms of clear serum may always be found in 
the peritoneal cavity, and when the amount which can be drawn 
from the tube reaches two or three drachms at five or six hours' 
interval, and this fluid is clear or nearly approaches straw color, 
the time for the withdrawal of the tube has come. A drainage- 
tube should be cleansed as often as it becomes necessary, no atten- 
tion being paid to the shortness or length of time. Immediately 
following the operation it should be emptied every fifteen minutes 



682 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

or half hour. It should never be allowed to go sufficiently long to 
overflow and soil the dressings. As the quantity of fluid decreases, 
the interval of cleansing is lengthened, until by the end of twenty- 
four hours it is generally not necessary to clean it oftener than once 
in three hours. 

Sometimes in twenty-four hours the tube may be withdrawn, 
or it may be necessary to allow it to remain for a week : about 
three days is the average length of time. In withdrawing the 
tube it is only necessary, after removing all the dressings, to 
make traction upon it, meanwhile rotating it as it is drawn out. 
The same careful antisepsis is to be observed in removing as in 
cleansing it. A small piece of antiseptic gauze is placed over the 
opening left by the withdrawal of the tube, and the wound edges are 
drawn together with a strip of adhesive plaster. The dressings are 
replaced, and not disturbed again until the stitches are removed. 

In some cases the surgeon fears that the pelvis or certain parts of 
it may suppurate or that a fecal fistula may form, and yet the drain- 
age-tube is ready, from all appearances, to be withdrawn a day after 
the operation. Under these circumstances it is best to allow it to re- 
main for three or four days, cleansing it only often enough to have 
an idea of what is going on at its lower extremity — possibly twice 
in the twenty-four hours unless the symptoms indicate otherwise. 

Should suppuration occur, the tube is to be kept in place untiL 
the amount of pus discharged begins to diminish, when it may be 
withdrawn and the opening gradually allowed to contract. During 
the acute stage of suppuration the tube should be cleansed every 
few hours and washed out with boracic-acid solution : later, after 
it has been dispensed with, peroxide of hydrogen is the most effi- 
cient wash for cleansing and disinfecting the tube-track. The open- 
ing generally closes in a week or two, or if not, the condition be- 
comes chronic and possibly a permanent fistula may result. As a. 
rule, these fistulous tracts close in time, even after existing for 
several years. 

Should the drain be of gauze instead of glass, the care of it will! 
be somewhat different. The gauze drains by capillary action, and 
keeps the dressings continually wet, so that it is necessary to change 
them frequently. The whole arrangement of the abdominal dress- 
ing is such that the parts about the drain may be changed with- 
out removing all. The one commonly used is that known as the 
Mikulicz drain. It consists of a gauze bag containing a number 



AFTER- TREA TMENT IN G YNECOL O GICAL OPERA TIONS. 683 

of pieces of gauze, the end of each piece protruding from its mouth. 
In withdrawing the drain the pieces are picked up with a pair of 
dressing forceps and withdrawn separately ; as they are removed 
the bag collapses, and is easier withdrawn than if the whole 
drain was removed together. In drawing out the bag care should 
be taken that no pieces of intestine or omentum follow, as at times 
is apt to be the case : should this occur the viscus is to be replaced 
at once with the forceps and the edge of the wound drawn together 
with the ligature which was placed for that purpose at the time 
of operation, or by a strip of adhesive plaster, care being taken 
that intestine or omentum be not included between the lips of the 
wound. Any kind of drainage is an indication of incompleted sur- 
gery, possibly unavoidably so, but nevertheless incomplete, and is to 
be avoided whenever and wherever possible. Drainage should only 
be tolerated with the distinct understanding that it is a necessary 
evil, but only necessary occasionally. Abdominal surgery should 
be and is possible with not more than a maximum of 5 or 10 per 
cent, of drainage cases — probably less. 

Dressings. — An ordinary case of abdominal section need not 
have the original dressing removed until the time has arrived to 
take out the stitches. Should a drainage-tube be in use, the dress- 
ing may become soiled, when it will be necessary to change it, or if 
the incision or the stitch-tracks suppurate, it will be advisable to 
remove the dressing, not only to replace it by a clean one, but in 
order to apply remedies to the suppurating parts. A full week 
should elapse before disturbing the stitches. Stitch-hole abscesses 
may arise before the stitches are removed or afterward. The 
stitches should be taken out on the eighth day unless suppura- 
tion has previously occurred, when it may become necessary to 
remove them immediately. This procedure is accomplished by 
picking up one of the strands of the stitch by the aid of a pair 
of hemostatic forceps, lifting the knot out of its bed, and exposing 
both strands of the stitch below the knot. The blades of a pair 
of scissors are opened, and made to include one of the strands 
as it dips down into the tissue; the scissors are pressed down 
into the skin at the same time that the knot is elevated by the 
forceps. This procedure exposes a portion of the ligature, which 
has been buried in the tissue, and which is white and clean and 
has not been infected. The ligature is cut in this uninfected 
area. As the cut end is drawn through the tissues in its removal, 



i 



684 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

there is no danger of dragging infection with it, when if the stitch 
had been cut above the skin-surface a portion of contaminated suture 
would infect, in many cases, the suture-track. In this manner are 
caused stitch-hole abscesses which form after the stitches have been 
removed. After the one strand of the stitch is cut, the knot is to be 
drawn in the direction across the incision, not away from it. Should 
it be drawn away from the incision, there is an excellent chance that 
the skin-union will be separated at points, and possibly throughout 
its whole extent. 

After the stitches have been removed the parts about the incis- 
ion should be cleansed with a piece of cotton clipped in a solution of 
bichloride of mercury, care being taken not to disturb the line of 
union. The dried clots may be left alone, else in their removal 
some raw surface may be exposed. A small piece of antiseptic 
gauze is to be placed over the incision, and the parts held together 
by several strips of adhesive plaster, a binder being placed over 
the whole. Usually no more attention need be paid to the 
wound. 

If the incision suppurates, it is best to remove the stitches at once, 
allow the superficial parts of the wound to separate, and treat the 
incision as an open wound by disinfecting and packing. The cicatri- 
cial tissue resulting from this method of healing will be the surer 
barrier to a future hernia. If stitch-hole abscesses exist, it is only 
necessary to provide for their drainage. Usually as the stitch is 
withdrawn the pus will flow from the opening left by its removal, 
and it may be necessary to empty the abscess once or twice a day 
by gently squeezing it, care being taken not to exert too much 
pressure : the abscess will, as a rule, heal within from two days 
to a week. A considerable rise of temperature and pulse may 
accompany these abscesses, but the symptoms disappear almost at 
once after drainage has been provided. While suppuration goes 
on the dressing should be changed twice daily and the parts thor- 
oughly cleansed. It should be treated, in fact, like any suppurating 
wound. If any of the cavities are very large, it may be well to 
inject them with peroxide of hydrogen or bichloride-of-mercury or 
other antiseptic solution. 

Hemorrhage. — For hemorrhage following an abdominal section 
there is but one treatment. As soon as the surgeon is reasonably 
certain that serious bleeding is going on, the wound must be opened 
and the bleeding vessel ligated. Attempts to apply any other treat- 



AFTER-TREATMENT IN GYNECOLOGICAL OPERATIONS. 685 

meat are useless, and the less time lost the more chance there will be 
of saving the patient. Care should be taken in re-opening the wound 
that everything is just as aseptic as at the original operation. 

If a drainage-tube has been used, it will usually indicate that 
bleeding is taking place, but this is not to be depended upon 
for an indication as to how much blood is being lost. The abdo- 
men has been opened and found filled with clots when the tube pro- 
jecting into its cavity had been cleaned every ten or fifteen minutes, 
and it was supposed that all the blood had been withdrawn. Even 
if the tube does not indicate that a dangerous amount of blood is 
being lost, if the constitutional symptoms look strongly suspicious, 
the abdomen had better be re-opened and the bleeding vessel tied. 
The constitutional symptoms will be the same as those of con- 
cealed hemorrhage from any other cause. If the bleeding comes 
from torn adhesions, and is simply a free ooze, no alarm need be 
felt concerning it. It matters not how free it may be at first, it 
will last but a short while. The indications are to keep the drain- 
age-tube perfectly dry, so as to favor coagulation of the blood and 
consequent cessation of the bleeding. The oftener the tube is 
cleansed and the drier the pelvis is kept, the sooner will the hem- 
orrhage cease. 

If the patient, having rallied from her ether, with a good pulse 
and practically normal temperature, be found in the course of 
the next twenty-four hours to be showing indications of collapse, 
together with a rising pulse and a falling temperature, hemor- 
rhage will almost always be found to be at the bottom of the 
trouble. The pulse under these circumstances becomes feeble, 
and is rapid and running in character. The temperature and pulse, 
together with the general condition of lassitude and growing indif- 
ference, are almost pathognomonic of the condition. If the bleed- 
ing be allowed to continue, these symptoms gradually deepen, and 
the more advanced indications of collapse, such as great pallor, sigh- 
ing, and cold surface, supervene. Intravenous infusion or infusion 
into the loose subcutaneous connective tissues of a sterilized (when 
possible) salt solution is often urgently demanded. 

Shock. — The symptoms of shock may readily be mistaken for 
hemorrhage, the difference being that in hemorrhage the indications 
do not begin for some hours after operation, while in shock they are 
present from the first. Otherwise, the two present so many points 
of likeness that it is at times difficult to say which is present. The 



686 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

indications for treatment in shock following abdominal section are 
exactly the same as for that condition from any other cause — dry 
heat applied to the whole surface of the body, care being taken not 
to burn the skin with the hot cans or bottles ; whiskey, ammonia, 
nitro-glycerin, and digitalis may be used as necessary adjuncts in the 
treatment. Strychnia is, according to some physicians, the most valu- 
able of all drugs for this condition, and may be given freely without 
fear. It should be given hypodermically in doses of one-twentieth 
of a grain repeated every half hour for two or three hours, and 
then each hour until the patient is decidedly better or shows signs 
of muscular twitching. It is far better to take the chances of 
producing strychnia-poisoning than to give two small a quantity. 
If the patient can be carried over the shock, it will be time enough 
afterward to attend to the poisonous symptoms. 

Sepsis. — The management of this complication will depend much 
upon the character and extent of the infection. A general pelvic 
and abdominal septic peritonitis following abdominal section is never 
cured : the patient invariably dies. For more than two days it is 
doubtful just what is the trouble with the patient; in fact, one can- 
not be certain that there is anything seriously wrong. By the time 
it is reasonably certain that there is septicemia to deal with, the 
patient is beyond relief, and is dead before the end of the fourth 
twenty-four hours after the operation. Usually the condition of 
the patient immediately following the operation is fairly good, but 
within the first twenty-four hours the pulse gradually and almost 
imperceptibly creeps up until it reaches 110 to 120 beats to the 
minute. It is weak and inclined to be running. The temperature 
simultaneously ranges in the neighborhood of 100 or more degrees. 
The ether-vomiting is prolonged beyond the usual limit of twenty- 
four hours, when most probably the stomach will have an interval 
of rest for six or eight hours before the secondary vomiting due to 
the septicemia sets in. 

During this interval of rest from vomiting the pulse grad- 
ually but steadily creeps higher and higher, becomes more rapid 
and weak, and finally thready. The temperature at the same 
time becomes more and more elevated. The abdomen becomes 
distended, due partly to flatulence and partly to the retention 
of the purgatives and nourishment. In spite of all efforts to 
move the bowels, no indication of borborygmus or of passage of 
flatus can be obtained. The stomach finally begins to expel every- 



A FTEB- TBEA TMENT IN G YNECOL O GIGA L OPERA TIONS. 687 

thing placed in it. The rectal enemas are promptly rejected. Pro- 
fuse sweating and cold creeps set in. The dull, heavy muscular 
pains of septic poisoning supervene. The patient becomes restless, 
tossing from one side of the bed to the other. The facial expression, 
which has been gradually becoming more and more anxious, deepens, 
and the patient assumes an altogether hopeless appearance. Prior 
to death the pulse becomes so rapid and weak as to be impercepti- 
ble : the temperature may rise even to 106° or 107°, and the body 
is bathed in a cold, clammy perspiration. The vomited matter is 
dark brown. 

No effort should be spared to secure a passage of the bowels 
until the trouble has plainly manifested itself. 

Whiskey and strychnia should be given to the point of tolerance, 
many of these patients taking from a pint to a quart of whiskey in 
the twenty-four hours without showing signs of its constitutional 
effect. Quinine in large doses is a valuable adjunct to the manage- 
ment. The hypodermic needle and rectal enemas must for the most 
part be depended upon for the administration. 

If at the end of sixty hours there is no longer doubt as to the 
complication, it is useless to make further effort, other than to ren- 
der the patient's death as easy as possible. Under these circum- 
stances opium is the one drug to depend upon. It will relieve the 
pain and suffering, and that is all it is in the power of the physician 
to do for his patient. Theoretically, the proper treatment would be 
to open the abdomen, irrigate it thoroughly and introduce a drain- 
age-tube. It would probably be best to do this as early as twenty- 
four or thirty-six hours after operation should by any chance the 
diagnosis be made, but even at this early period it is more than 
doubtful whether any good would be accomplished. When the 
abdomen is opened the condition found will be that of a general 
matting together of the pelvic organs and those loops of intestines 
and omentum hanging into the pelvis. An ounce or two of dark 
fluid will be observed on breaking up the adhesions. The only 
effect obtained will be to expose more surface to absorption by sepa- 
ration of the adhesions. If any good can be accomplished in this 
direction, it will be by providing free and continuous irrigation of 
the whole pelvic cavity for several days or until such time as the 
patient is convalescent. If the infection be introduced at the time 
of the operation, and be given twenty-four or thirty-six hours in 
which to develop, the case is practically hopeless. The diagnosis 



688 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

cannot possibly be arrived at earlier than at the end of forty-eight 
hours with any degree of certainty. 

Should a local suppuration occur about the pedicle or elsewhere 
in the pelvis and an abscess result, the condition is amenable to 
treatment and the patient will easily recover. The symptoms 
induced by the abscess will be the ordinary ones of septic infection, 
which, taken in conjunction vrith the knowledge obtained from 
the operation, will readily indicate their true cause. For the first 
few days the patient progresses favorably. Movements of the 
bowels are obtained in response to the purgatives and enemas, but 
not of a satisfactory character. The pulse remains high, from 100 
to 120 beats to the minute, but fairly good in character. The tem- 
perature ranges from 100° to 102°, or higher, with a daily evening 
elevation. The patient may at times reject her food, having little 
or no appetite. Her mental condition is clouded, and she com- 
plains of dull pains and cold creeps. Her general condition is 
heavy and lethargic. Night-sweats are present. The abdomen is 
more or less distended, and colicky pains are apt to disturb her in 
consequence. These symptoms are of more gradual development 
than those of general septic infection of the pelvic cavity. At no 
time do they become so intense, and seldom threaten speedy death. 

The only proper treatment is to empty the abscess and drain 
the cavity after having washed it out. It may be necessary to 
reopen the abdomen to accomplish this, or the posterior vaginal cul- 
de-sac may be opened, a finger passed into the pelvic cavity, and 
adhesions penetrated until the purulent matter be found. The parts 
are then gently irrigated and loosely packed. Frequently in these 
cases a drainage-tube has been used in the pelvis, and it is then most 
probably near the seat of the abscess. Under these circumstances, 
if the symptoms will allow of delay, it is best to wait for a few 
days, or even a week if necessary, in hopes that the abscess will 
rupture into the drainage-tube, which it generally will do. Should 
the temperature, pulse, and other symptoms become alarming at 
any time, the lower end of the incision had best be opened, and 
the abscess sought in the pelvis amid the adherent intestines and 
opened with the finger, care being taken not to invade, if possible, the 
general peritoneal cavity. If the pus be thoroughly washed away, 
the temperature and pulse will fall almost immediately to normal, 
and the other symptoms will disappear coincidently. Stimulation 
by whiskey, strychnia, and quinine is to be begun early and car- 



A FTER- THE A TMENT IN G YNECOL O GICA L OF ERA TIONS. 689 

ried out freely, only stopping short of the physiological action of the 
drugs. Septic symptoms due to stitch-hole abscesses are to be treated 
as already described under the head of Dressings. 

Fistula. — These are either simple suppurating, fecal, or urinary. 
The simple suppurating fistula is the most common. It is generally 
due to an infected tube-track or to septic ligatures. The majority 
of fistulse close eventually without special treatment for which 
reason they should be treated expectantly rather than by a sec- 
ondary operation. If they are caused by an infected ligature, 
they will not heal until the ligature has come away, when they 
usually close very promptly. Various methods have been pro- 
posed for removing the ligature through the fistulous track with- 
out re-opening the abdomen. A pair of small-bladed forceps may 
be passed into the opening and an attempt made to catch the offend- 
ing body : the introduction of pieces of twisted wire and various 
other devices have been adopted, with success in exceptional cases. 
The silk will eventually work itself free and appear at the mouth 
of the fistula. Few fistulse remain open unless there is a foreign 
body present as the cause : the exception occurs in women who are 
probably suffering from tubercular or other general conditions. 

Under any circumstances the sinus should be kept clean and 
free from the discharges ; at the same time the general health 
should be looked after, and if there is any condition such as 
tuberculosis present, it should be treated accordingly. Perox- 
ide of hydrogen diluted with water — half and half — or in its 
pure state is probably the best wash which can be used. It 
is to be passed, by the aid of a syringe, to the bottom of the 
fistula and allowed to regurgitate, the injection being kept up 
until it comes away clear and clean without any appearance of 
froth : it would be well to wash the sinus out several times daily, 
the dressings being changed frequently enough to keep the parts 
clean. 

It is proper to wait from three to six months, or even longer, 
before attempting any radical procedure. The operation necessitates 
opening the abdominal cavity, with all the chances of infecting the 
peritoneum with the discharges of the sinus. Should the operation 
be undertaken, the parts must first be thoroughly disinfected, and 
the sinus washed out with peroxide of hydrogen and a solution of 
bichloride of mercury. The abdomen is opened, the adhesions 
broken up to the bottom of the fistula, and the ligatures removed : 

44 



690 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

the walls of the fistula should be curetted away as far as possible. 
Should no ligature be found, the walls of the sinus must be thor- 
oughly destroyed. In closing the abdomen a drainage-tube must 
be introduced for a few days in order to guard against possible sup- 
puration. 

Nothing can be done for chronic fecal fistulas short of an ope- 
ration, except to keep the parts clean. It is not always advis- 
able to attempt an operation in these cases, for the reason that 
the opening in the bowel is often so low down in the rectum 
that it is impossible to bring the parts within reach so that sutures 
can be properly placed : in addition, the tissues of the gut are often 
so badly disorganized that stitches will not hold, and a resection 
would be necessary, when from the low position of the opening this 
would be impossible. If the operation is undertaken, the parts 
must be thoroughly cleansed and disinfected ; the bowels should be 
purged and the rectum washed out by an enema. After invading 
the abdominal cavity the adhesions between the coils of intestines 
are to be carefully separated down to the opening in the bowel. 

Occasionally in old chronic cases the fistula can be dissected out 
as a complete tube down to the intestinal or>ei ing, in which case 
there would be a minimum danger of infecting the peritoneal cavity. 
Under any circumstances the edges of the fistula are to be freshened 
and turned into the gut, sutures being so placed as to retain the 
edges in apposition. If the opening is sufficiently high to allow 
of a resection of the bowel, this may become necessary, provided 
it cannot be closed. Should it not be possible to close the 
hole or to resect the gut, a drainage-tube must be so placed as to 
drain the immediate vicinity of the injured bowel, and the tube 
cleansed every fifteen minutes to allow of no spread of infection until 
sufficient lymph has been thrown about the seat of danger to pro- 
tect the peritoneal cavity: in the mean time sufficient opium is 
given to keep the bowels quiet. 

The operation for chronic fecal fistula is a tedious and dangerous 
one, and often results in failure or in disaster. It is the only hope 
of relief, however, and it is justifiable to take considerable risk with 
the hope of gaining a cure. 

The primary treatment of fecal fistula is one of rest. Should the 
fistula occur three or four days after operation, enough lymph will 
have been thrown out to protect the general peritoneal cavity, 
and there will be little danger. Should it be discovered during the 



AFTER-TREATMENT IN GYNECOLOGICAL OPERATIONS. 691 

first few hours, while cleaning the drainage-tube, the tube must be 
cleansed at intervals of not longer than fifteen minutes, and the 
bowels kept quiet by the use of opium for three or four days at 
least. When the bowels have once opened, they should not be 
allowed to again become constipated, but daily evacuation should 
be secured by the use of laxatives. 

In the course of a week the tube may safely be withdrawn, and 
the fecal matter allowed to flow through the track formed by the 
lymph. As long as the tube is in place the opening will not close, 
but as soon as it is removed the parts begin to contract, and grad- 
ually the flow of fecal matter becomes less and less, until finally in 
a few weeks it has ceased altogether. Most fecal fistulas will close 
spontaneously if treated properly from the first. 

Hernia. — This is one of the common sequelae of abdominal sec- 
tion, and is due to a failure of union between the cut edges of the 
muscles and fasciae. The hernia usually does not appear for some 
weeks after the woman is out of bed, and then only as a small 
protrusion at one point, from which it gradually spreads, until, if 
neglected, it at tim occupies the whole of the original incision. 
As a prophylactic measure against this accident the longer the 
patient is kept in bed after her operation the better : too early get- 
ting up puts a strain on the newly-united incision and predisposes 
to hernia. When the hernia has once appeared, but two courses 
are open — either to use support at the opening and if possible pre- 
vent it from becoming larger, or to perform a secondary operation 
for its cure. A properly-fitting truss will keep the intestines back 
and to a great extent render the woman comfortable, but there is 
no chance whatever of the opening ever closing if left to itself. 

In making the incision, great care must be observed in opening 
the abdominal cavity at the seat of the hernia, for the reason that 
the intestines are very apt to be adherent to the sac. The anatom- 
ical relations are all destroyed, and there is no certain guide as to 
where the knife is about to enter the peritoneal cavity. After the 
abdominal cavity is opened the old incision should be split to the 
full extent of the hernia both above and below. The peritoneal 
and adventitious tissue covering the edges of the muscle and fascia 
completely around the opening must be trimmed away with the 
scissors and knife, and the redundant portions of the sac resected. 
The edges of the several tissues are brought into apposition and 
the wound closed in the usual way after an abdominal section. 



1 



692 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



Various methods of repairing hernias have from time to time 
been used with varying degrees of success, but all the indications are 
met by the above method, especially if an extra and separate row 
of sutures be placed in the muscles and fascia in order to secure 
and retain their coaptation. Either silk or silkworm-gut may be 
used for this purpose. Silkworm-gut is preferable as it gives a per- 
manent support to the tissues, while silk is apt to become weak- 

Fig. 341. 




Sutures in place for the Repair of Ventral Hernia. 

ened by absorption. Subsequently the patient should be kept 
upon her back for not less than four weeks, to allow of thorough 
healing. Should the buried sutures suppurate, it is due to faulty 
technique, and they must be removed before the resulting fistula 
will heal. 

The usual length of time for a patient to remain in bed following 
an abdominal section is at least three weeks. During the early 



AFTER-TREATMENT IN GYNECOLOGICAL OPERATIONS. 693 

part of the fourth week the patient may be allowed to sit up in bed, 
and by the end of the week she may begin to go about her usual 
duties. It is well, however, that she make a semi-invalid of herself 
for some weeks or more where this is possible, and secure the addi- 
tional rest from work and worry. For six months or a year after 
the operation an abdominal binder should be worn, at the end of 
which time it may gradually be dispensed with. The neglect of 
these precautions often results in a very considerable amount of 
future discomfort to the patient. 

Every woman who has had both uterine appendages removed 
suffers from symptoms of the menopause. Generally these are 
more stormy than those accompanying the natural menopause. 
Until this change is fully established the patient will not receive 
the full benefit of the operation. The condition requires treatment, 
and the indications are to be met as they arise in the way such 
symptoms are usually met in the natural menopause. The phe- 
nomena are essentially nervous, and the indications are for general 
tonics and nerve-sedatives. 

As has been already noted, the infection which gives rise to the 
disease, requiring an abdominal section in pelvic inflammation, pro- 
ceeds from the vagina or the uterus into the Fallopian tubes. The 
removal of the uterine appendages does not always cure the case, 
but is merely the necessary preliminary step. Some cases are com- 
pletely cured by the changes which go on in the uterus incident to 
the menopause, but in others, in spite of this, the womb remains 
enlarged, heavy, and engorged, and the leucorrheal discharges and 
hemorrhages remain just as profuse as before the operation. These 
cases require local treatment of the diseased uterus ; otherwise a sat- 
isfactory result is not usually obtained except after a long interval. 
The womb should be thoroughly curetted, and the case treated as is 
proper in a case of endometritis and subinvolution. At times, 
however, the prolonged effect of the menopause is too much for 
even these cases, and they eventually, after several years, are re- 
lieved of their symptoms without any local treatment ; other cases 
require that the womb be removed. 

Phlegmasia Alba Dolens. — The attack begins, as a rule, about the 
end of the second or third week after operation, at a time when the 
patient is in apparent perfect health. Pain appears suddenly in 
the hip, followed by swelling of the part. The skin is hot to the 
touch and the temperature is elevated. The swelling and pain 



694 AN AMERICAN TEXT- BOOK OF GYNECOLOGY. 

spread rapidly downward, until within twenty-four hours the whole 
leg is involved. The tissues are hard to the touch, with no evidence 
of edema. In a few days the leg becomes less hard and the 
swelling and pain subside. At no time is there redness along 
the veins. The condition is accompanied by no septic symptoms. 
The complication may occur either upon the side upon which an 
ovary has been removed or upon the opposite side. One leg alone 
is affected, most generally the left. The condition remains for 
two or three weeks and even longer before the last trace has dis- 
appeared. We have known one case to last a year. 

The leg is to be surrounded by soft pillows and an application of 
laudanum and lead-water made. This is to be kept up until the 
pain is relieved, after which the treatment consists principally of 
absolute rest in bed. A light diet and a withdrawal of stimulants 
are advisable. Friction is to be avoided. The etiology of the 
condition is not known. 

Plastic Operations. 

The after-treatment of plastic operations resolves itself into rest 
and cleanliness. The patient should be kept in bed two weeks, after- 
which she may take another week in getting up and about. As in 
abdominal section, the longer she remains in bed the better for her, 
and where a patient can be made content, a month is not too long a 
time, especially for prolapse cases. If a gauze tampon has been 
introduced into the vagina, it should be removed within forty-eight 
hours, and need not be renewed. A warm vaginal douche of 
boracic acid should be administered daily, care being taken not to 
make any pressure on the points of suture. The douche should be 
used for the purpose of cleanliness, after which a single strip of 
gauze an inch or two in width may be passed if desired into the 
cul-de-sac with the aid of dressing forceps. This accomplishes the 
desired drainage with the minimum interference with the seat of 
operation. Especial care must betaken in this regard when cat- 
gut sutures have been introduced. 

In cases of uterine curettement, if the cavity of the womb has 
been packed with gauze, the packing should be removed at the 
end of forty-eight hours and the vagina thoroughly cleansed by 
an antiseptic douche. Afterward an antiseptic vaginal douche 
should be administered daily. If instead of the gauze a drain- 
age-tube has been introduced into the uterus at the time of ope- 



A FTEB- THE A TMENT IN G YNECOL O GIGA L OPERA TIONS 695 

ration, it should be removed daily, cleansed, and replaced. This 
can readily be accomplished by placing the patient in the left 
lateral position in her bed and introducing a perineal retractor. 
The cervix being exposed and steadied by drawing it down 
with a tenaculum, the drainage-tube is caught in a pair of dress- 
ing forceps, withdrawn from the uterus, cleansed, and at once 
replaced. It will be perfectly easy before replacing the tube to 
wash out the uterus with an antiseptic solution by the aid of a David- 
son's syringe with a rectal nozzle attached. 

When a cancerous cervix has been removed by the aid of the 
curette and scissors, the tampon, which has been placed in great 
part to control the subsequent bleeding, should be allowed to re- 
main for forty-eight hours, at the end of which time it may be 
removed. This is done with the patient lying in the left lateral 
position in her bed ; the vagina and wound are then cleansed and 
disinfected, and a fresh tampon replaced, provided there be any 
signs of bleeding. If there be no bleeding, a single strip of 
gauze to provide for drainage is all that will be required. This 
should be renewed daily after each antiseptic douche. 

The bladder is to be catheterized only in case of necessity, and 
unless there has been an operation on the anterior wall of the 
vagina the instrument will rarely be needed. In cases of repair of 
vesico-vaginal fistulse, the bladder must be kept empty, either by 
frequent use of the catheter or by a self-retaining catheter for four 
or five days, or until such time as it is safe to allow the urine to 
accumulate and the bladder to empty itself. This is especially 
necessary where a ureter has been cut and subsequently stitched 
into the bladder. The bowels may in all cases be opened the day 
following the operation ; a daily passage should be secured there- 
after; this holds equally good for tears of the perineum involving 
the sphincter. A dose or two of magnesium sulphate should be 
administered, and as soon as there is any manifest desire for defeca- 
tion an enema should be at once given, so as to secure as easy and 
as soft a passage as possible. If bleeding occurs after an operation, 
it is best that it should be given an opportunity to stop of its own 
accord. This usually occurs, but should it persist, hot vaginal 
douches may be given, and if these do not control it, resort to a 
vaginal tampon may be necessary, even though it spoil the opera- 
tion. The tampon should only be used as a last resort : it will 
rarely be needed. 



696 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

Except in cases of lacerated perineum where the sphincter is 
involved, or in cases of recto-vaginal fistulse, the patient may be 
allowed anything to eat or drink she may desire. It is just as 
well in these two injuries to confine the diet to such articles 
as will leave little residue, so that there shall be as small an 
amount of fecal matter as possible. It will not be necessary to 
restrict the diet for more than four or five days. The stitches in 
plastic operations should be removed on the eighth or tenth day : 
after which time nothing in the way of treatment is necessary, 
except to see that the vaginal douche be given daily and that 
the bodily functions act properly. If a combined operation for the 
repair of the cervix and perineum has been performed, great care 
will have to be exercised in removing the stitches from the cervix, 
lest the union of the perineal wound be disturbed. For this reason 
the stitches in the cervix at the time of operation should be allowed 
to remain long and should be shotted. If this precaution be ob- 
served in placing the sutures, it will be easy subsequently to remove 
them by making traction upon the long sutures, and thus bring- 
ing the cervix into view, requiring a minimum amount of stretching 
of the perineum with the perineal retractor. The patient should 
be placed on a table in the dorsal position for their removal. If 
the same precaution be observed in regard to the placing of the 
stitches in the perineum, no difficulty will be met with in their 
removal. So great is the facility with which this can be done that 
even the nurse can be trusted with the removal of the perineal 
stitches. Should there be much discharge from the parts, a bichlo- 
ride-of-mercury or a permanganate-of-potash douche may be sub- 
stituted for that of boracic acid, and it may be given two or three 
times daily. This is especially necessary in the after-treatment 
of vaginal hysterectomies. 

The after-treatment of this operation is very tedious, great care 
in regard to details being necessary. 

Once each half hour the nurse makes inspection of the vulva, 
to see that there is no bleeding, and every two hours the catch of 
the catheter, which has been introduced into the bladder, is released 
and the bladder evacuated. Forty-eight hours after the opera- 
tion the patient is put upon the table and the forceps removed. 
Each pair is removed in the following way: Undoing the catch 
of the forceps, the operator separates the handles to a distance 
which indicates that the points of the instrument are a quarter 



AFTER-TREATMENT IN GYNECOLOGICAL OPERATIONS. 697 

of an inch apart ; then, grasping each blade of the forceps in the 
hands, a rocking motion from side to side is applied at the same 
time that gentle traction is made. After loosening the forceps and 
before beginning to withdraw them it may be well to wait a few 
minutes before removing them, to see whether bleeding takes place ; 
if so the forceps are immediately closed again, the patient given 
a few drops of chloroform, the vaginal packing removed, and the 
bleeding point sought for and seized by forceps. The forceps hav- 
ing been removed, the bladder is washed out with a saturated solu- 
tion of boracic acid and the self-retaining catheter withdrawn. The 
first dressing is not removed before a week, and is then taken away 
under chloroform narcosis. The vaginal dressing of sterile gauze 
is removed and renewed daily thereafter. Two days after the first 
dressing the patient is allowed to be raised in bed, and to sit up in 
bed after the second dressing. At the time of operating the cavity 
should not be irrigated, lest pus be washed up beyond possibility of 
removal. It is better to depend upon swabbing away all discharges 
with sterile gauze. During the time of the suppuration which fol- 
lows the use of clamps the patient is mentally dull and sluggish ; the 
temperature and pulse will be found slightly elevated, and there will 
be a loss of appetite evidenced. She is, in fact, suffering from a 
mild form of septic infection due to absorption of the purulent dis- 
charges from the wound. For these reasons it is the more import- 
ant, in order to secure the comfort and possible safety of the 
patient, that greater attention be paid to local disinfection and 
cleanliness. Deodorizing and disinfecting vaginal douches should 
be used daily after the first dressing has been removed and general 
mild stimulation administered. 

Should a ureter have been included in either of the ligatures 
or clamps during the operation, symptoms of uremia will quickly 
develop, and the patient in most cases will be lost. For the first 
few days it will be uncertain whether the patient is suffering 
from the shock of the operation, septicemia, or uremia. By 
the time the true cause of the trouble is determined with rea- 
sonable certainty the patient will probably be beyond help. The 
symptoms which will lead one to suspect this condition are a dimi- 
nution in the quantity of urine passed, the elevation and rapidity 
of the pulse and temperature, the low mental condition, together 
with restlessness and anxious expression of the countenance, — all 
beginning early. The diminution of the quantity of the urine is 



698 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

the only one of all these symptoms pointing directly to the kid- 
ney as the seat of the trouble ; and when it is considered that the 
amount of urine secreted after an operation is under all circum- 
stances exceedingly small in the first twenty-four or forty-eight 
hours — often being less than ten ounces in the twenty-four hours 
— it will be seen of how little practical value this symptom 
really is. 

If the condition be diagnosed, the proper treatment consists in 
removing the clamps or ligature and freeing the ureters. Should 
the ureters have been cut in addition to having been clamped,, 
their cut ends may be freed from the compressing force and turned 
into the vagina ; if the patient recover, at a subsequent operation 
the ureters may be turned into the bladder or the corresponding 
kidney be removed. If there is any uncertainty as to which side is. 
involved, catheterization of the ureters is our only method of deter- 
mining the question. This procedure is valuable in excluding liga- 
tion of one or both ureters as a possible cause of the symptoms. 

Should the bladder have been opened during the operation, and 
for any reason remain unclosed, great care should be taken not 
to allow any accumulation of urine. For this purpose a self-retain- 
ing catheter should be introduced, and retained in place until all 
chance of spontaneous closure is passed. If the opening remains 
permanently, subsequent operation must be made for its closure, it 
being treated in the interim as an ordinary case of vesico- vaginal 
fistula. 



INDEX. 



Abdomen, method of opening, 62 
Abdominal cyst, 582 

hemorrhage, after-treatment, 684 
hysterectomy, 410 
incision, closure of, 62, 63 
operations, closure of the incision in, 63 

dressing the wound in, 64 

opening the abdomen in, 62 

preparatory treatment in, 60 
pregnancy, 519 
section, after-treatment, 670 
tumor, adhesions of, 591 

exploratory puncture of, 592 

pedicle of, 591 

treatment, 593 
wall, fatty, 588 
Abnormalities of the cervix uteri, 130 
of the clitoris, 123 
of the Fallopian tubes, 130 
of either or both genital zones, 120 
of the hymen, 123 
of the ovaries, 131 
of the uterus, 125 
of the vagina, 124 
of the vulva, 123 
Abortion, solicitation of patients for, 90 
tubal, 525 

diagnosis, 536 
Abscess-cavities, multiple, in pyosalpinx, 
491 
of the labia, 158 
of the ovary, 452, 462 

diagnosis, 463 

prognosis, 474 

symptoms, 453, 462 
pelvic, 447 

course, 447 

drainage of, 488 

evacuation of, 489 

extraperitoneal treatment, 492 

neglected, 516 

opening into bowel, 489 

symptoms, 447 

treatment, 490 
stitch-hole, 683 

treatment, 684 
suburethral, cause, 626 

diagnosis, 626 

symptoms, 626 

treatment, 626 
of vulvo-vaginal glands, 157 
Absence of the clitoris, 123 
of the Fallopian tube, 130 
of the genital organs, 122 
of the hymen, 124 



Absence of the internal genital organs, 125 
of the labia majora, 123 
of the nymphse, 123 
of the ovary, 131 
of the uterus, 125 
of the vagina, 124 
Absorbent cotton, sterilization of, 54 
Adenoma, benign, of the uterus, 196 

malignant, of uterine mucous mem- 
brane, 378 
ovarian, 565 

papillary, of the uterus, 197 
Adhesions, bread-and-butter, 445 
labial, 153 

from neglected pelvic abscess, 517 
of the ovary, 444 

and Fallopian tube, 443 
in pelvic peritonitis, 465 
separation of, 445 
spider-web, 444 
After-treatment of bladder in operations, 
675 
in gynecological operations, 670 
of operations, bathing in, 678 
drainage-tube in, 680 
dressings in, 683 
drink in, 672 
flatulence in, 678 
food in, 672 
purgatives in, 673 
rest in, 670 
vomiting in, 671 
Alexander's operation, 299, 302 
anatomy, 293, 302, 303 
difliculties of, 300, 306 
indications for, 301 
Amenorrhea, 86 
causes, 86 
diagnosis, 88 
prognosis, 89 
treatment, 90 
Amputation of cervix, 373 

after-treatment, 338, 376 
. by galvano-cautery, 375 
high, 373 
procedure in, 374 
simple, 333 

vaginal, in inversion, 352 
wedge-shaped, 335 
of the uterus for prolapse, by Baldy's 
method, 327 
Anesthesia for examination, 29 
Angioma of the vulva, 172 
Anomalies of the female generative organs, 
118 



700 



INDEX. 



Anteflexion, 268 

applications to endometrium in, 275 

bladder-attachment in, 271 

complications, 270 

dilatation in, 276 

drugs in, 277 

effect of lacing on, 271 

forms of, 268 

indications for operation in, 276 

intra-abdominal pressure in, 271 

with menopause, 277 

treatment, 278 
pathology, 269 
physiologic changes in, 271 
with retroversion, 270 

treatment of enlarged cervix in, 
273 
stem-pessaries in, 275, 276 
symptoms, 269 
treatment, 272, 273 

after operation for, 276 
stenosis in, 275 
for sterility in, 273 
in unmarried and married, 270 
Anterior colporrhaphy, 338 

Sims's operation for, 338 
"Stoltz's operation for, 339 
Antisepsis in gynecologic operations, 44, 45 
Apoplectic ovum, 528 

Application to the endometrium in ante- 
flexion, 275 
Applications, uterine, 203 
Applicators, uterine, 34 
Apron of Hottentot, 152 
Areolar cyst of the ovary, 563 
Artificial impregnation in sterility, 116 
Ascites from ovarian cyst, 578 

diagnosis of, from ovarian cyst, 586 
Asepsis, 45 
Aspirator, 42 

Assistants, preparation of, 48 
Astringents, 96 
Atresia of the hymen, 123 
of the urethra, 619 
treatment, 619 
of the vagina, 176 
course, 177 
diagnosis, 178 
prognosis, 180 
symptoms, 178 
treatment, 180 
varieties, 177 
Atrophic endometritis, 200 

Baldy's operation for prolapse, 326 
indications for, 329 
ligatures in, 327, 328 
modification of, 329 
results of, 328 

Ball pessary, 332 

Barrenness, 111 
treatment, 115 

Bartholin's glands, inflammation of, 157 

Bassini's operation, 305 

Bathing in after-treatment of operation, 
678 



Benign uterine neoplasms, 387 
Bicornate uterus, 127 

diagnosis of, from abdominal cyst, 
584 
Bimanual examination, 25 

palpation in pelvic inflammation, 
thorough, 460 
Bipartite bladder, 622 
Bladder, absence of, complete, 628 
adenoma of, 653 
in anteflexion, 271 
bipartite, 622 
carcinoma of, 653, 369 
care of, after operation, 675 

in operative treatment of reposi- 
tion of uterus, 298 
congenital malformation of, 628 
cystoscope in the, 611 
dermoid cyst of, 653 
displacement of, 632 

diagnosis, 632 

downward, 632 

symptoms, 632 

treatment, 632 

upward, 632 
distended, 589 
double, 629 

examination of, artificial landmarks in, 
614 

natural landmarks in, 614 

with cystoscope, 613 
exstrophy of, 629 

forms of, 629 

operations for, 631 

symptoms, 630 

treatment, 630 
extroversion of, 629 
foreign body in, 633 

diagnosis, 634 

symptoms, 634 

treatment, 634 
implantation, sutures in, 660 

ureter in, 660 
incision in, after-treatment of, 698 
injuries to, in ovariotomy, 604 
neoplasms of, after-treatment on re- 
moval of, 657 

diagnosis, 655 

from the epithelium of, 653 

etiology, 654 

from the muscularis, 653 

operations for removal of, 655 

symptoms, 654 

treatment, 655 
palliative, 657 
papilloma of, 652 

previous preparation of patient in dis- 
ease of, 611 
prolapse of, 632 

diagnosis, 633 

symptoms, 633 

through a patulous urethra, 632 

treatment, 633 
sarcoma of, 653 

separation of, from uterus in hysterec- 
tomy, 412 



IXDEX. 



701 



Bladder, sutures in, after operation on neo- 
plasm of, 657 
tuberculosis of, 649 
diagnosis, 650 
pathological anatomy, 649 
symptoms, 650 
treatment. 651 
tumor of. 652 
Bloodletting in pelvic inflammation. 479 
Bowels, care of, after coeliotomy, 677, 679 
in pelvic inflammation, management 
of, 476 
Braun's coipeurynter. 321, 322, 350 

intra-uterine syringe, 213 
Bread-and-butter adhesions, 44-5 
Broad-ligament cyst, 544, 559 
micro-cyst of, 560 
papillomatous, disease of, 384 
structure in, diagram of, 558 
Byford's uterine elevator, 33 

Calcification of fibroid, 392 

of ovarian cyst. 566 
Calcified corpus iuteum. 566 
Calculus of the ureter, 664 
diagnosis, 665 
symptoms, 665 
treatment, 666 
vesical, 634 

diagnosis, 637 
etiology, 635 
prognosis, 638 
symptoms, 636 
treatment, 638 
varieties, 635 
Carcinoma of bladder, 356 
of cervix, 366 

after-treatment. 377 
causes, 367 
course, 367, 368, 370 
diagnosis, 370 
discharges in, 377 
forms. 367 
symptoms, 368 
treatment, 372 
palliative. 373 
radical. 373 
ulceration in. 371 
of the ovary, 382 
symptoms, 384 
treatment, 385 
periurethral, 356 
of the ureter, 668 
of the urethra, 356 
treatment. 356 
of the body of the uterus, 378 
diagnosis, 380 
symptoms, 379 
treatment. 381 
of the uterus, probability of return after 

operation, 382 
of the vagina, 35S 
diagnosis, 358 
etiology, 358 
symptoms, 358 
treatment, operative, 359 



Carcinoma of the vagina, treatment, pal- 
liative, 359 
of the vulva, 355 
Carcinomatous infiltration, extent of, 372 
Caseous tuberculosis of the peritoneum, 147 
Catarrhal salpingitis, 455 
diagnosis, 457 
physical signs in, 455 
Catgut, sterilization of, 52 
Catheter, renal, 610 

self-retaining, in vaginal hvsterectomy, 

510 
ureteral, 612 
urethral, 610 
Catheterization of Fallopian tube, 443 

of ureter. 667 
Caustics, the use of, in carcinoma of cervix, 

376 
Cautery, galvano-, 375. 401 
Cellulitis, pelvic, 431, 446. 466 
diagnosis, 466, 467 
physical signs in, 454 
prognosis. 474 
symptoms, 454 
Cervical artery, rupture of, 232 
Cervix, abnormalities of, 130 
amputation of, 373 

bv galvano-cautery, 375 
high, 373 
simple, 333 
antero-posterior section of, for ante- 
flexion, 273 
carcinoma of, 366 

after-treatment in. 377 

operation in, 695 
course, 367, 368, 370 
diagnosis, 370 
forms of, 367 
hemorrhage in, 368 
symptoms, 368 
treatment, 372 
palliative. 373 
radical, 373 
ulceration in, 371 
cicatricial stenosis of. 226 
cystic degeneration of, 223 
digital examination of, 21 
dilatation of, 211 
elongation of, 331 

treatment, 333 
epithelioma of mucous membrane of, 

367 
fibroid polyp of, 387 
fixation to" abdominal wall after hys- 
terectomy. 330 
glandular polyp of, 223 
hypertrophy of, 226 
inflammation of, 222 
laceration of, 231 

after-appearance of, 232 
bilateral. 232 
immediate repair of, 232 
incision in the angles of, 235 
method of denudation in, 236 
operation for, 235 
preparatory to operation, 234 



702 



INDEX. 



Cervix, laceration of, sutures in,. 236 
symptoms, 232 
unilateral, 233 

mucous membrane of, 191 

and perineum, after-treatment in com- 
bined operation on, 696 

scarification of, 479 

section of, in anteflexion, 274 

supravaginal hvpertrophy of, 330 
pathology, 330 
symptoms, 331 
treatment, 331 

tuberculosis of, 135 
Cessation of menses, 86 
Chancre of the vulva, 163 
Chancroid of the vulva, 163 
Change of life, 71 

Changes following removal of uterine ap- 
pendages, 516 
Chloride-of-zinc pencils, treatment of endo- 
metritis with, 201 
Climacteric, 71 
Clitoris, absence of, 123 

hypertrophy of, 152 

tumor of, 171 
Cloaca, recto-vaginal, 124 
Coccygodynia, 172 
Coccyx, pain in, 172 

palpation of, 24 

tenotomy of, 172 
Cceliotomv, after-treatment of, 670 

bathing after, 678 

care of bladder after, 675 

cystitis after, 677 

drainage-tube in. 680 

dressings after, 683 

drink after, 672 

fistulse after, 689 

flatulence after, 678 

hemorrhage after, 684 

hernia after, 691 

phlegmasia alba dolens after, 694 

purgatives after, 673 

rest after, 670 



shock in, 685 
technique of, 60 
vomiting following, 671 
Colic, uterine, 102 
Colpeurynter, Braun's, 350 
Colpo-perineorrhaphv, 323, 340 

object of, 340 
Colporrhaphy, anterior, 323, 338 
Complete rupture of the recto-vaginal sep- 
tum, 247 
causes, 248 
immediate operation for, 

249 
intermediate operation 

for, 251 
secondary operation for, 

252 
symptoms, 248 
Conception, requirements on part of woman 

to, 272 
Condyloma of urethra, 627 



Congenital retroflexion, 278 

retroversion, 278 

Conical dilators, 609 

Corpus luteum, calcification of, 566 

cyst of, 561 

typical, 547 

Counter-irritation in pelvic inflammation, 

480 
Curettage in acute pelvic inflammations, 
after-treatment, 219 
after amputation of the cervix, 338 
in endometritis, 202, 206 
in Freund's operation, 324 
in hysterectomy, 411 
after ovariotomy, 502 
in pelvic inflammation, 476 
in pelvic inflammations, 214 
in posterior vaginal section, 468 
for post-operative menstruation, 513 
in prolapse, 323 
in prophylaxis of pelvic inflammation, 

476 
technique of, 210 
in vaginal hysterectomy, 504 
Curette, dull, 42 
uterine, 212 
Cyst, abdominal, 582 

pedicle in all varieties of, 571 
areolar, 563 
of broad ligament, 544 
of corpus luteum, 561 
dermoid, 567 

contents of, 567 
diagnosis, 399 
of Fallopian tube and ovary, 559 
of the hydatid of Morgagni, 560 
micro-, of broad ligament, 560 
m unilocular, 564 
of the ovary, 511 
ascites in. 578 

atheromatous changes in, 566 
calcification of, 566 
character of, 565 
complicated by uterine myomata, 

587 
course, duration, and termination, 

578 
diagnosis of, from ascites, 586 
emptying of, 594 
etiology, 571 

fatty degeneration of, 566 
glandular, proligerous, 563 
hemorrhage in, 574 
intestinal obstruction from pres- 
sure of, 578 
large, 562 
physical signs, 580 
proliferating, 579 
results of pressure from, 573 
rupture of, in ovariotomy, 602 
simple or follicular, 561 

etiology, 561 
strangulation from pressure of, 578 
symptoms, 571 

and uterus, removal by hemisec- 
tion, 511 



INDEX. 



703 



'Cyst, parovarian, 570 
tubo-ovarian, 561 
unilocular, 563 
of the urethra, 628 

causes, 628 

symptoms, 628 

treatment, 628 
of the vagina, 188 
of the vulva, 169 
Cystic tumor, diagnosis, 590 

mistaken diagnosis, 589 
Cystitis, 640 

chronic, treatment, 646 

Emmet's operation in, 649 
diagnosis, 645 

dilatation of urethra in, 648 
diphtheritic, 643 
drainage in, 649 
etiology, 640 

manner of entrance of organisms 
in, 641 

predisposing causes, 642 
exfoliative, 643 
forms, 642 
hematuria in, 645 
organisms found in, 642 
pain in, 644 

pathologic anatomy, 643 
prognosis in, 646 
symptoms, 644 
treatment, 646-648 
tubercular, 649 

diagnosis, 650 

pathologic anatomy, 640 

symptoms, 650 

treatment, 651 
urine in, 644 
Cystocele, 316 

Stoltz's operation for, 340 
Cystoma, glandular, 564 
of ovary, 383 
papillary, 566 
proliferating, 562 
Cystoscope, 608 

in the bladder, 611 
in diagnosis of calculus, 637 
introduction of, 613 
Kelly's, 609 
Cystotomy for calculus, 640 

Decidtja from ectopic gestation expelled 
from uterus, 533 
photomicrograph of, 535 
menstrualis, 81 
reflexa, 84 

in situ in ectopic gestation, 534 
vera, 84 
Defectus uteri, 125 
Dermoid cyst, 567 

contents of, 567 
diagnosis, 399 
ovarian, 568 
Deschamp's needle, 410-413, 415 
Desmoid tumor, 588 
Didelphic uterus, 1 29 
Diet in pelvic inflammation, 481 



Diffuse sarcoma of uterus, symptoms, 363 
Dilatation of the cervix, 211 

of the genital tract for examination, 38 

of the urethra, 41 

of the uterus, gradual, 40 

rapid, 40 
without curettage in anteflexion, 276 
Dilator, conical, 609 

uterine, 40 
Diphtheria of the vulva, 160 
Douche, vaginal, 186, 478 
Douches in pelvic inflammation, 478 
Drainage in after-treatment of operation, 
680 
gauze, 682 
glass tube, 601 

in neglected pelvic abscess, 517 
in ovariotomy, 600 
of pelvic abscess, 488 
after removal of uterine appendages, 
501 
Drainage-tube, glass, 501, 680 
care of, 680 
suppuration with, 682 
syringe for cleansing, 680 
time for removal of, 681 
use of, 681 
Drains, glass, 56 

Mikulicz, 55, 682 
roll-gauze, 55 
sterilization of, 55 
Dressings for abdominal incision, 306 
after abdominal section, 683 
in after-treatment of operation, 683 
sterilization of, 54 
Drink in after-treatment of operation, 672 
Dudley's operation for retrodisplacement 

of the uterus, 300 
Dull curette, 42 
Duplex uterus, 129 
Dysmenorrhea, 97 

in anteflexion, 275 
congestive, 99 

diagnosis, 104 
prognosis, 104 
symptoms, 102 
treatment, 107 
description of, 97 
diagnosis, 103 
intermenstrual, 98 
mechanical, 100 
diagnosis, 104 
prognosis, 104 
symptoms, 102 
treatment, 107 
membranous, 100, 535 
prognosis, 105 
symptoms, 101, 103 
treatment, 109 
neuralgic, 99 

diagnosis, 103 
prognosis, 104 
symptoms, 101 
treatment, 105 
ovarian, 100 

prognosis, 105 



704 



INDEX. 



Dysmenorrhea, ovarian, symptoms, 103 
treatment, 104 

pathology of, 99 

prognosis, 104 

treatment, 105 

varieties of, 99 
Dysuria, 316 

Ecraseur, 405 

in hysterectomy, 406 
Ectopic gestation, 518 

decidua from, 533 

photomicrograph of, 535 
diagnosis, 532 
etiology, 519 
exciting causes, 521 
extra-peritoneal rupture of, treat- 
ment, 541 
with fibroid of uterus, 534 
galvano-puncture in, 539 
hemorrhage in, 522 
history, 518 

intraperitoneal rupture of, treat- 
ment, 540 
pathology, 510 
period of rupture of, 527 
periods in treatment, 538 
peritoneum in, 523 
result of rupture in, 522 
rupture of, fetal life continuing in, 
542 
into peritoneal cavity, 524 
transverse section of pelvis in, 524 
treatment, 538 

electricity in, 539 
tubal, rupture in, 540 
tubo-peritoneal, 524 
varieties, 518 
menstruation, 82 
Eczema of the vulva, 159 
Electricity in amenorrhea, 92 

in treatment of ectopic gestation, 539 
of endometritis, 220 
of pelvic inflammation, 484, 485 
Elephantiasis of the vulva, 168 
Elevator, uterine, 32 
Byford's, 33 
Sims's, 32 
Elongation of cervix, 331 

treatment, 333 
Emmenagogues, 91 
Emmet's operation for calculus, 640 

of trachelorrhaphy, 323 
Endocervicitis, 222 
glandular, 223 
gonorrheal, 222 
septic, 222 
treatment, 225 
Endometritis, electricity in, 220 
glandular, 197 
gonorrheal, 208 
pathology, 208 
symptoms, 208 
treatment, 209 
interstitial, 200 
septic, 204 



Endometritis, septic, acute, 204 

chronic, 205 

symptoms, 205 

treatment, 206 

simple, 195 

atrophic, 196 

symptoms, 200 
hypertrophic, 195, 198 
treatment, 201 

applications in, 203 
Endometrium, anatomy of, 190 
applications to, 203, 276 
method of reproduction of, 217 
physiology of, 192 
treatment of, for dysmenorrhea, 276 
Epispadias in the female, 123 
Epithelioma of cervical mucous membrane, 
367 
of cervix, 312 
of external genitals, 353 

development of, 353 
etiology, 354 
treatment, 355 
ulcers in, 354 
of the uterine mucosa, 378 
of the vagina, 358 
diagnosis, 358 
etiology, 358 
symptoms, 358 
Ergot, treatment of fibroid tumors of the 

uterus by, 400, 401 
Erysipelas of the vulva, 160 
Examination under anesthesia, 29 
bimanual, 25 
digital, per rectum, 23 

per vaginam, 21 
dilatation of the genital tract for, 38 
by instruments, 30 
ocular, 20 

of the female pelvic organs, 17 
preparation for, 18 
rectal, 461 

Simon's method of, 38 
by speculum, 33 
of the vaginal entrance, 29 
Exstrophy of the bladder, 629 
symptoms, 630 
treatment, 631 
External genitals, epithelioma of, 353 

malignant diseases of, 353 
Extra-uterine gestation, 518 
decidua from, 533 

photomicrograph of, 535 
diagnosis, 532 
etiology, 519 
exciting causes, 521 
extraperitoneal rupture of, treat- 
ment, 541 
with fibroid of uterus, 534 
galvano-puncture in, 539 
hemorrhage in, 522 
history, 518 

intraperitoneal rupture of, treat- 
ment, 540 
pathology, 520 
period of rupture of, 527 



INDEX. 



705 



Extra-uterine gestation, periods in treat- 
ment, 538 
peritoneum in. 523 
result of rupture in. 522 
rupture of. fetal life continuing in. 
542 
into peritoneal cavity, 524 
transverse section of pelvis in, 524 
treatment. 538 

electricity in, 539 
tubal rupture in. 540 
tubo-peritoneal. 524 
varieties, 518 
menstruation, 82 

pregnancy, diagnosis from hematosal- 
pinx, 458 
exciting causes. 521 
Extroversion of'the bladder. 629 
symptoms. 630 
treatment. 631 

Fallopian tube, abnormalities of. 130 

absence of, 130 

anatomy of. 548 

bimanual palpation of, 27 

displacements of. 552 
treatment. 552 

function of, 550 

gravid. 521 

of Macaque monkey. o45 

malformation of, 551 

normal, 433 

and ovary, adhesions of, 443 
showing adhesions, 438 

of Panoliau deer, 549 

pregnant. 527 

rupture of. directions of. 522 

section of, 550 

stricture of uterine opening of, 438 

tuberculosis of, 139 
Fecal fistula, 265 

tumor. 589 
Female genitalia, malignant diseases of, 353 
Fergusson speculum. 657 
Fibroid of the uterus, 389 

calcareous degeneration of, 392 

cause of death from. 396 

classification. 389 

complicated bv ectopic gestation, 
534 

complications met during hyster- 
ectomy for. 417 

diagnosis. 396 

general symptoms. 396 

hemorrhage in. 395 

hvsterectomv for. results of, 420 

interstitial. 391. 392 

nodular. 394. 403 

pain in. 394. 399 

pathology. 389 

pedunculated. 393 

polyp. 387 

' of uterus, 388 

pressure-symptoms in, 395 

removal by morcellatiou, 402 

submucous. 390. 397 



Fibroid of the uterus, subperitoneal, pedun- 
culated. 391 
subserous, method of removal of,404 
summary of treatment of, 420 
symptoms, 394 
treatment, 400 

by electricity, 401 
by ergot, 400 

general considerations in, 418 
by vaginal enucleation, 402 
tuberculosis of~the peritoneum, 146 
of the vagina. 189 
of the vulva, 169 
Fibroids, intraligamentous, 398, 409, 417 
Fibroma of ovary, 569 
Fibro-myoma of uterus. 389 

interstitial, diagnosis, 397 
submucous, diagnosis, 396 
subserous, diagnosis, 398 
! Fibro-myomata of ovary, 568 
j Fibro- sarcoma of uterus, 361 

symptoms, 363 
Fistula in cceliotomv. 512 
fecal, 257, 265, 689 

after ovariotomy, 604 
symptoms, 266 
treatment, 690 
genital, 257 

after gynecologic operations, 689 
indications for methods of treatment, 

260. 261 
indications for time of treatment, 260 
intervisceral, 512 
persistent, treatment, 260 
recto-vaginal, 266 
sutures in, 267 
treatment, 266 
ureteral, diagnosis, 258 
suture of, 259 
treatment, 258 
uretero-vaginal, treatment, 259 
urethral, 265 

treatment, 265 
urinary, 257, 689 
vaginal, 262 
causes. 262 
complications. 263 
forms and sizes, 262, 263 
sutures in operation for, 264, 265 
treatment, 263 
vesical, various forms of. 259 
vesico-uterine, 259 

treatment, after operation, 689 
vesico-utero-vaginal, 262 
vesico- vaginal. 262 
Flap splitting method for complete lacera- 
tion, 345 
for incomplete laceration. 344 

objections to. 344 
for perineorrhaphy. 344 
Flatulence after operation. 678 
Flexion of uterus as a cause of sterility, 272 
Food in after-treatment of operation, 672 
Forceps, mouse-toothed. 610 
Foreign body in bladder. 633 
diagnosis, 634 



706 



INDEX. 



Foreign body in bladder, symptoms, 634 

treatment, 634 
Freund's operation, 324 

cases suitable for, 326 
Frozen section of Berry Hart, 523 

Galvano-puncture in ectopic gestation, 

539 
Gartner's duct, 570 
Gauze, sterilization of, 55 
Genital fistula, 257 
Genitalia, absence of, 119 
anomalies of, 118 
external, absence of, 119 
development of, 118 
internal, anomalies of, 125 
tuberculosis of, 132 
Gestation, ectopic, 518 
diagnosis, 532 
etiology, 519 
exciting causes, 521 
history, 518 
pathology, 520 
period of rupture of, 527 
peritoneum in, 523 
results of rupture in, 522 
tubo- peritoneal, 524 
varieties, 518 
tubal, 518 

varieties, 519 
Glandular cystoma, 564 
Glass drains, 57 
Gonorrheal vulvitis, 162 

Hands, preparation of, for operation, 48 
Hegar's operation for artificial menopause, 
419 
for colpo-perineorrhaphy, 323, 340 
profile view of, 342 
Hematocele, pelvic, 530 

from ectopic gestation, 537 
etiology, 531 
physical signs, 531 
Hematoma, pelvic, 530 
changes in, 532 
from ectopic gestation, 537 
etiology, 531 
physical signs, 531 
of the vulva, 164 
Hematometra, 82 

in cancer of the cervix, 369 
Hematosalpinx, 436, 449, 459 
diagnosis, 458 

from extra-uterine pregnancy, 458 
physical signs in, 455 
prognosis, 473 
symptoms, 449 
Hematuria from calculus, 636 
Hemisection of uterus in vaginal hyster- 
ectomy, 51 1 
Hemorrhage after celiotomy, 684 
constitutional symptoms, 685 
differentiation of, from shock, 685 
following abdominal section, 684 
Hemostatics, 96 
Hermaphrodism, classification, 120 



Hermaphrodism, pseudo-, 121 

true, 120 
Hernia, after coeliotomy, 691 

after gynecologic operation, 691 
labialis inguinalis, 166 
pudendal, 166 
vaginalis labialis, 166 
ventral, 588 

possibility of, 309 
sutures in place for repair of, 692 
Herpes of the vulva, 158 
Hottentot apron, 152 
Hydatid of Morgagni, cyst of, 560 
Hydramnios, 584 

Hydrocele of the labium majus, 165 
Hydronephrosis from prolapse, 312 
Hydrosalpinx, 534, 435, 448 
diagnosis, 458 
physical signs, 449, 455 
prognosis, 473 
symptoms, 449 
Hymen, absence of, 124 
anomalies of, 123 
imperforate, 176 
Hyperesthesia, vulvo-vaginal, 173 
Hyperinvolution, 229 
Hypertrophic endometritis, 198 
Hypertrophy of cervix, supravaginal, 330 
pathology of, 330 
symptoms, 331 
treatment, 331 
of external genitals, 152 
Hypnotism in amenorrhea, 92 
Hypospadias, 619 
in female, 123 
treatment, 619 
Hysterectomy, abdominal, operation of, 411 
complete operation for, 414 
adhesions found in, 417 
cervical stump in fixation after, 330 
complications met in operation of, 417, 

418 
for fibroid, 410 

general considerations, 419 
results, 420 
in inversion, 352 
operation of, 415, 416 
supravaginal, 405 

extraperitoneal amputation, meth- 
od of, 405 
intra-abdominal method, 407 
total abdominal, 410 
vaginal, 502 

after-treatment, 696 
clamp operation of, 503 
dangers of, 513 
when the uterus is large, 511 
delivery of adnexa in, 507, 508 
hemisection of uterus in, 511 
importance of removal of adhesions 

in, 509 
incisions in, 504 
instruments in, 512 
manner of delivering fundus in, 

505, 506 
steps in, 505, 506 






INDEX. 



707 



Hysterorrhaphy, 301, 307 
effects of, 310 
object of, 310 
objections to, 309 
performance of, 307, 308 
sutures in position in, 307 

Imperforate hymen, 176, 178 
Incision in Alexander's operation, 304 

post-vaginal, 481 
Incomplete rupture of the recto-vaginal 
septum, 239 
denudation of, 242 
suture of, 244 
symptoms, 241 
treatment, 241 
Infertility, 111 

Infravaginal elongation of the cervix, 331 
Infusion, intravenous, 67 
saline, Q6 
subcutaneous, 67 
Instrumental examination, 30 
Instruments, preparation of, 49 
Internal genital organs, absence of, 125 
Interstitial myoma of uterus, enucleation 
of, 405 
ovaritis, 449, 459 

symptoms, 449, 450 
salpingitis, 449, 459 
prognosis, 473 
symptoms, 449, 450 
tubal pregnancy, 525 
diagnosis, 526 

direction of rupture in, 526 
with intraperitoneal rupture, 
treatment, 543 
Intestinal obstruction from pressure of cyst, 

578 
Intestines in vaginal hysterectomy, 509 
Intraligamentous fibroid, 409 

modification of intra-abdominal 
method of hysterectomy for, 409 
Intravenous infusion, 67 
Inversion of the uterus, 347 
causes, 347 

causes of death in, 348 
diagnosis, 348 
hysterectomy in, 352 
prognosis, 349 
symptoms, 347 
Thomas's operation for, 351 
treatment, 349 
Iodine in endometritis, 202 
Iodoform gauze in vaginal hysterectomy, 509 
Iodoformized gauze, sterilization of, 55 
Irrigation of vagina, 186 

Kelly's pad, 62 
Knee-chest position, 20 

for vaginal tamponade, 322 
Knot, Staffordshire, 498 

Tait's, 498 
Kraurosis vulvae, 175 

Labia, abscess of, 158 
absence of, 123 



Labia, adhesions of, 153 
hernia into, 166 
hydrocele of, 165 
majora, absence of, 123 
hypertrophy of, 152 
minora, hypertrophy of, 152 
Laceration of the cervix uteri, 231 
after-appearance of, 232 
bilateral, 232 
immediate repair of, 232 
incision in the angles of, 235 
method of denudation in, 236 
operation for, 235 
preparatory treatment to opera- 
tion for, 234 
sutures in, 236 
symptoms, 232 
unilateral, 233 
Lacerations of the perineum, 238 

as a cause of prolapse, 313 
Lateral flexions, 278' 
Left lateral position, 19 
Ligature, braided silk, 414 
catgut, 599 

figure-of-eight, 497, 498 
preparation of, 50 
rubber, method of fastening, 406 
silk, 414 

triple interlocking, 599 
Lipoma of the vulva, 171 
Lithotomy position, 415 
Lithotrity, 638 

after-treatment in, 640 
contraindications to, 639 
Lupus of the vulva, 132 

Malformation of bladder, congenital, 628 
Malignant diseases of the external genitals. 
353 
of the female genitalia, 353 
of the vagina, 357 
Massage in pelvic inflammation, 486, 487 
Mechanical dysmenorrhea, 100 
diagnosis, 103 
prognosis, 105 
symptoms, 102 
treatment, 105 
Membranous dysmenorrhea, 535 
Menopause, 71 

with anteflexion, 277 
artificial, 73, 514 
definition, 71 
description, 71 
diagnosis, 74 

effect of, on pelvic inflammation, 473 
Hegar's or Tait's operation for arti- 
ficial, 419 
irregular, 73 
pathology, 74 
prognosis, 75 

after removal of appendages, 501, 513 
sudden, 73 
synonvms, 71 
time of, 73 
treatment, 75 
Menorrhagia, 93 



708 



INDEX. 






Menorrhagia, causes, 93 

pathology, 95 

prognosis, 95 

treatment, 95 

between periods, 96 
Menses, retention of, 82 
Menstrual discharge, amount of, 79 
composition, 78 
source, 79 

pad, 85 
Menstruation, 69 

absence of, 86 

after removal of appendages, 513 

appearance of, 71 

associate symptoms, 81 

cessation of, 86 

duration, 70 

during pregnancy, 84 

ectopic, 82 

excessive, 93 

management of, 85 

and ovulation, 83 

painful, 97 

in pelvic inflammation, 451, 476 

regularity of, 69 

suppression of, 85 

synonyms, 69 

theories of, 83 
Methods of examination, 20 
Metritis, 227 
Metrorrhagia, 93 

Micro-cyst of broad ligament, 560 
Mikulicz drain, 55, 682 
Miliary tuberculosis of the peritoneum, 142 
Morcellation of fibroid of uterus, 403 
Miillerian ducts, faulty development of, 130 
Multilocular cyst, 564 
Myomata of uterus complicating ovarian 

cyst, 587 
Myomectomy, 404 

Needle, bayonet-pointed, 308 
Deschamp's, 410, 416 
exploratory, 42 
Hagedorn, 341 
Neoplasm, benign uterine, 387 
of the bladder, diagnosis, 655 
etiology, 654 
symptoms, 654 
treatment, 655 
of the urethra, 627 
Neuralgic dysmenorrhea, 99 
diagnosis, 103 
prognosis, 104 
symptoms, 101 
treatment, 105 
Noma, 160 

Nuck, canal of, dilatation of, 166 
Nymphse, absence of, 123 
hypertrophy of, 152 

Obesity, 587 
Ocular examination, 21 
Oophorectomy, 593 
Oophoritis, 555 
acute, 555 



Oophoritis, acute, course, 556 

etiology, 556 

symptoms, 556 

termination, 556 

treatment, 556 
Operating-room, preparation of, 46 
Operational hernia, 691 
Operations, bathing after, 678 
care of bladder after, 675 
cystitis after, 677 
dressings after, 683 
drink after, 672 
fistula after, 689 
flatulence after, 678 
general details for, 65 
hemorrhage after, 684 
hernia after, 691 

phlegmasia alba dolens after, 694 
preparations for, 43 
purgatives after, 693 
rest after, 670 
sepsis in, 686 
shock in, 685 
technique of, 43, 60 
vomiting after, 671 
Operator, preparation of, 48 
Outlet, vaginal, relaxation of, in dorsal po- 
sition, 240 
in Sims's position, 241' 
virginal vaginal, 238 
Ovarian abscess, 433 
adenoma, 565 
cyst, 511 

ascites in, 578 

calcification of, 566 

course, 578 

duration, 578 

etiology, 571 

hemorrhage in, 574 

intestinal obstruction from press- 
ure of, 578 

large, 562 

physical signs, 580 

proliferating, 579 

results of pressure from, 573 

symptoms, 571 

termination, 578 
dermoid, 568 
neoplasms, 559 
tumor, adhesions of, 575 

diagnosis, 581 

inflammation of, 574 

rupture of, 577 

suppuration of, 574 

symptoms, 575 

torsion of pedicle of, 576 
Ovariotomy, 593 

accidents during operation of, 601 
adhesions in, management of, 596 
adhesions following, 607 
bladder-injuries in, 604 
clamp method of, 598 
complications in, 605 

after operations for, 606 

intestinal, 606 
drainage in, 600 



INDEX. 



709 



Ovariotomy, hemorrhage in. 597 

fatal, 602 
intraperitoneal method of, 598 
operation of, 593 

for incomplete, 604 
pedicle in, 598 

cauterization of, 598 

transfixion of, 598 
peritoneum in, 594 

toilet of, 600 
rupture of cyst in, 602 
sequelae of, 605 
steps in, 594 
stripping off the parietal peritoneum 

in, 601 
trocar in, 595 
visceral injuries in, 603 
Ovaritis, acute, 555 

course, 556 

description, 555 

etiology, 556 

symptoms, 556 

termination, 556 

treatment, 556 
chronic, 556 

diagnosis, 557 

etiology, 557 

symptoms, 557 

treatment, 558 
interstitial, 449, 459 

chronic, 437 

symptoms, 449, 450 
Ovary, abscess of, 452, 462 

prognosis, 474 

and pyosalpinx, 440 

symptoms, 453, 462 
absence of, 131, 551 
adhesions of, 444 
anatomy and physiology of, 544 
anomalies of, 13i 
bimanual palpation of, 27 
carcinoma of, 382 

symptoms, 384 

treatment, 385 
congestion of, 553 

diagnosis, 554 

termination, 554 

treatment, 554 
cyst of, areolar, 563 

ascites from, 578 
diagnosis, 586 

atheromatous changes in, 566 

calcification of, 566 

character of, 565 

complicated bv uterine myomata, 
587 

emptying, 594 

fatty degeneration of, 566 

proligerous glandular, 563 

simple or follicular, 561 
etiology, 561 
cystomata of, 383 
displacements of, 552 

treatment, 552 
and Fallopian tube, adhesions of, 443 
showing adhesions, 439 



Ovary, fibroma of, 569 
fibro-myomata of, 569 
malformation of, 551 
papillomata of, 383 
prolapse of, 552 

diagnosis, 552 

etiology, 552 

treatment, 553 
sarcoma of, 385 

diagnosis, 386 

treatment, 386 
solid tumors of, 569 
third, 513 
tuberculosis of, 142 
Ovulation and menstruation, 83 

theories of, 83 
Ovum, apoplectic, 528 

changes in, in tubal pregnancy, 528 

Packing of uterus with gauze, 471 
Pad, Kelly's, 62 

menstrual, 85 
Pain after removal of appendages, 514 
menstrual, 97 

in pelvic inflammation, 450, 451, 480 
Palpation, bimanual, in pelvic inflamma- 
tion, 460 
of the coccyx, 24 
of the Fallopian tube, 27 
of the ovary, 27 
of the pelvis, 27 
of the round ligament, 27 
of the ureter, 22, 27 
of the uterus, bimanual, 26 
rectal, 27 
recto- vaginal, 28 
Papillary cystomata, 566 

excrescences of the vagina, 189 
Papilloma of the bladder, 652 
Papillomatous cystic tumor of ovary, 383 

disease of broad ligaments, 384 
Paquelin cautery in cervical carcinoma, 377 
in the intra-abdominal amputation 

method, 408 
in malignant growths of the vulva, 

356 
in ovariotomy, 499 
in removal of ovarian cysts, 598 
after total hysterectomy, 366 
Parovarian cyst, 570 
Pean retractor, 470 
Pean-Pryor trowel, 470 
Pedicle in all varieties of cyst, 571 
of ovarian tumor, torsion of, 576 
in ovariotomy, 598 
Pelvic abscess, 447 
course, 447 
drainage of, 488 
evacuation of, 489 
extraperitoneal, treatment, 492 
neglected, 516 

adhesions from, 517 
opening into bowels, 489 
sinus from, 517 
symptoms, 447 
treatment, 490 



I 



710 



INDEX. 



Pelvic adhesions in ovariotomy, 597 
cellulitis, 431, 446, 454, 466 

diagnosis, 466, 467 

physical signs in, 454 

prognosis, 474 

symptoms, 454 
floor, mechanism of, 317 
frozen section of, 290 
hematocele, 530 
hematoma, 530 
inflammation, 421 

acute, 434 

advisability of operation, 493 

after-effects of the treatment of, 
482 

after-treatment, 483 

cause, 423 

chronic, 461 

cceliotomy for, 494 

counter-irritation in, 480 

curettage in, 215 

diagnosis, 457 

douches in, 478 

gonorrhea as a cause of, 426, 427 

instruments as cause of, 424 

management of bowels in, 477 

massage in, 486, 487 

medication in, 484 

menopause in, 473 

menstruation in, 451, 476 

other operations than hysterectomy 
for, 515 

pain in, 450, 451, 480 

pathologic anatomy of, 428, 429 

prognosis, 472 

prophylaxis of, 475 

purulent, neglected, 516 

removal of adhesions in, 495 
of appendages in, 464 

results of, 433 

scarification of cervix in, 479 

septic infection in, 425 

traumatism per se in, 424 

treatment, 474 
results of, 482 

ultimate treatment, 492 
peritonitis, 453, 464 

acute stage, 465 

adhesions in, 465 

diagnosis, 464 

pathology, 431 

recurrent attacks of, 493 

septic, 432 

symptoms, 453 
Pencils, chloride-of-zinc, 202 
Perineal retractor, 36 
Perineorrhaphy, after-treatment, 343 

flap-splitting method, 344 
Perineum, action of sphincter ani in pro- 
moting laceration of, 314 
after-treatment of operation for repair 

of, 696 
and cervix, after-treatment of combined 

operation on, 696 
laceration of, 238 

as a cause of prolapse, 313 



Perineum, repair of, after-treatment of 

operation for, 696 
Perioophoritis, 555 

Peritoneal cavity, rupture of ectopic gesta- 
tion into, 524 
Peritoneum, adhesions of, process in, 442 
in Baldy's operation, 328, 329 
in ectopic gestation, 523 
toilet of, in ovariotomy, 600 
tuberculosis of, 142 
caseous, 147 
fibroid, 145 
miliary, 142 
in vaginal section for reposition of ute- 
rus, 297 
Peritonitis, acute, complicated by inflam- 
mation of appendages, 502 
electricity to remove lymph in, 442 
pelvic, 453, 464 
acute, 465 
adhesions in, 465 
diagnosis, 464 
fibrinous form of, 431 
pathology, 431 
recurrent attacks of, 493 
serous forms of, 431 
suppurative form of, 431 
symptoms, 453 
suppurative, 440, 441 
Periureteritis, 662 
etiology, 662 

pathological anatomy, 662 
Periurethral carcinoma, 356 

symptoms, 356 
Pessary, 322 

action of, 293 
benefit of, 296 
for complete prolapse, 296 
contraindication to, 293 
hollow rubber ball, 322 
introduction of, 293 
in pelvic inflammation, 483 
with ring or cup, 296 
Smith-Hodge, 293, 484 
soft-rubber ring, 293 
stem, 296 
use of, 293 
Phantom tumor, 586 
Phlegmasia alba dolens, 693, 694 
after operation, 693 
treatment, 694 
Physometra, 585 
Plastic operations, 333 

after-treatment, 694 
Plug, glass, vaginal, 175 
Polyp, fibroid, of cervix, 387 
of uterus, 387 

symptoms, 388 
treatment, 388 
glandular, of the cervix, 223 

of the uterus, 198 
urethral, 628 
vesical, 652 
Position, dorsal, 612 
knee-chest, 20 

for cystoscopic examination, 611 



INDEX. 



711 



Position, knee-chest, in pelvic inflammation, 
483 
in prolapse, 332 

in replacement of the uterus, 287 
left lateral, 19 

in pelvic inflammation, 483 
lithotomy, in posterior vaginal section, 
468 
in vaginal hysterectomy, 504 
of a patient for examination, 19 
Sims's, 19 

in posterior vaginal section, 472 
in reposition of the uterus, 289 
Trendelenburg, 20 _ 

in intra-abdominal amputation , 407 
in ovariotomy, 499 
in posterior vaginal section, 471 
in removal of the uterine appen- 
dages, 495 
in total abdominal hysterectomy, 

410 
upright, 20 
Posterior pudendal hernia, 166 
Pregnancy, cornual, 518 
ectopic, 518 

decidua from, 533 

photomicrograph of, 535 
diagnosis, 532 
etiology, 519 
exciting causes, 521 
extraperitoneal rupture of, treat- 
ment, 541 
with fibroid of uterus, 534 
galvano-puncture in, 539 
hemorrhage in, 522 
history of, 518 

intraperitoneal rupture of, treat- 
ment, 540 
pathology, 520 
period of rupture of, 527 
periods in treatment, 538 
peritoneum in, 523 
results of rupture in, 522 
rupture of, into peritoneal cavity, 
524 
results of fetal life continuing 
in, 542 _ 
transverse section of pelvis in, 524 
treatment,' 538 

electricity in, 539 
tubal rupture in, 540 
tubo-peritoneal, 524 
varieties, 518 
extra-uterine, 578 

from catarrhal salpingitis, 436 
menstruation during, 84 
tubal, changes in ovum in, 528 
diagnosis, 532 
interstitial, 525 

direction of rupture in, 526 
period of rupture, 527 
physical signs in, 530 
symptoms, 529 
tubo-uterine, 525 
Preparation of patient, previous, in disease of 
urethra, ureter, and bladder, 611 



Preparations for an examination, 18 
Prolapse of the bladder, 632 
diagnosis, 633 
symptoms, 632 
treatment, 633 
of the intestines, 319 
of the ovary, 552 
diagnosis, 552 
etiology, 552 
treatment, 553 
of the urethra, 620 
diagnosis, 620 
symptoms, 620 
treatment, 620 
of the uterus, 310 
acute, 319, 325 

causes, 310, 311, 313 
treatment, 326 
complete, 313 

formation of, 314, 318 
pathology, 311 
ulceration in, 314 
consequences of, 312 
diagnosis, 320 
mesial section of, 312 
physiology, 317 
prognosis, 321 
retroposition in, 318 
symptoms, 319 
tamponade of vagina in, 322 
treatment, 321 
varieties, 311 
Proliferating cyst of ovary, 579 
Prurigo of the vulva, 159 
Pruritus vulva?, 160 
causes, 160 
diagnosis, 161 
treatment, 161 
Pryor's operation for intraligamentous 

fibroids, 415 
Pseudo-hermaphrodism, 121 
Puberty, 546 
Pudendal hernia, 166 
Puerperal septicemia as a cause of pelvic 

inflammation, 425 
Purgatives in after-treatment of operation, 
673 
in pelvic inflammation, 477 
Purulent salpingitis, 438 
Pyosalpinx,_452, 462 
diagnosis, 463 
double, 439 

multiple, abscess-cavities in, 491 
and ovarian abscess, 440 
prognosis, 474 
symptoms, 453, 462 
tubercular, 139 

Quilting ligature, 499 

Rapid dilatation of the uterus, 40 
Rectal examination, 27 

in pelvic inflammation, 461 
Rectocele, 314-316 

Hegar's operation for, 340 
Recto-vaginal fistula, 266 



712 



INDEX. 



Recto-vaginal fistula, treatment, 266 
septum, complete rupture of, 247 
causes, 248 
immediate operation for, 

249 
intermediate operation 

for, 251 
secondary operation for, 

252 
symptoms, 248 
incomplete rupture of, 239 
denudation of, 242 
suture of, 244 
symptoms, 241 
treatment, 241 
recent incomplete rupture of, 238 
sutures in, 238, 239 
ulceration of, 369 
Rectum, examination by, 23 
Reduction of retrodisplaced uterus by 

sound, 288, 291 
Relation of ureters and uterine arteries to 

cervix, 408 
Relaxation of the vaginal outlet in the 
dorsal position, 240 
in the Sims position, 241 
Removal of appendages, prognosis in, 514 
Renal calculus in ureter, 664 

catheter, 610 
Reposition of retroflexed uterus, bimanual, 
285, 286 
in fat women, 284 
in knee-chest position, 287 
of uterus, 284 

acquired retrodisplacement, ad- 
hesions in, 298 
adherent retrodisplaced, 289 
after-treatment, 292 
object of vaginal section in, 299 
operations by abdominal incision, 

299 
result of vaginal operation in, 297 
retrodisplacement, posterior vagi- 
nal section in, 297 
with the sound, 288 
Repositor, Sims-Pryor, 288 

uterine, 287 
Rest in pelvic inflammation, 476 
Retention of menses, 82 
Retractor, Pean, 470 

Retrodisplacements, acquired, adhesions of, 
291 
bimanual reposition of, 285 
complications of, 292, 301 
knee-chest reposition, 287 
object of surgical treatment, 297 
treatment, 284 

of complications, 301 
use of pessaries in, 292 

of uterine repositor in, 287 
bimanual replacement in, 281 
direction of intra-abdominal pressure 
in, 289 
Retroflexion, acquired, 280 

bimanual replacement of, 282-284 
reposition of, 285, 286 



Retroflexion, acquired, complicatious in, 281 
diagnosis, 283 
etiology, 280 
symptoms, 282 
treatment, 284 
with adhesions, 291 
congenital, 278 

operation in, 279 
symptoms, 279 
treatment, 279 
Retropositions, acquired, diagnosis in, 281 
Retroversion, acquired, 280 

complications in, 281 
symptoms, 282 
treatment, 284 
congenital, 278 
with anteflexion, 270 

treatment, 273 
without enlargement, treatment, 293 
Roll-gauze drain, 55 

Round ligament, manner of searching for, 
303, 304 
palpation of, 301 
in prolapse, 311 
shortening of, 299 

by Alexander's operation, 301 
by Dudley's operation, 300 
bv Wylie's or Baer's opera- 
tion, 299 
topographical anatomy of, 302, 303 
Rupture of ovarian tumor, 577 

of the recto-vaginal septum, complete, 
247, 248 
immediate operation for, 

249 
intermediate operation 

for, 251 
secondary operation for, 

249 
symptoms, 248 
incomplete, denudation of, 242 
old, 239 
recent, 238 
suture of, 244 
sutures in, 239 
symptoms, 241 
treatment, 241 

Saline infusion, 66 
Salpingitis, 448 

adhesions in, 438 
catarrhal, 436, 448 

diagnosis, 457 

physical signs, 455 

prognosis, 472 

symptoms, 448 
chronic, 437 

interstitial, 437 
interstitial, 449, 459 

prognosis, 473 

symptoms, 449, 450 
suppurative, 438 
tubercular, 139 
Sarcoma of the bladder, 653 
of the ovary, 385 

diagnosis, 386 



INDEX. 



713 



Sarcoma of the ovary, treatment, 386 
of the uterus, 361 
causes, 362 
diagnosis, 364, 365 
diffuse, prognosis, 365 
symptoms, 363 
treatment, 366 
of the vagina, 357 
diagnosis, 357 
prognosis, 358 
treatment, 358 
Scarification of cervix in pelvic inflamma- 
tion, 479 
Searcher, ureteral, 610 
Searching for ureteral orifice, 612 
Section of abdomen, after-treatment, 670 
of cervix, for anteflexion, 273, 274 
frozen, of Berry Hart, 523 
horizontal, above crests of ilium, 544 
of normal ovary, 547 
posterior vaginal, 468 
trausverse, of pelvis, in ectopic gesta- 
tion, 524 
Semen, artificial introduction of, into the 
uterus, 116 
44 
complications in, 688 
after gynecologic operations, 686 
from local suppuration, 688 

treatment, 688 
symptoms, 686 
treatment, 686-688 
Septicemia, puerperal, a causation of pelvic 

inflammation, 425 
Serre-noeud for hysterectomy, 406 
Shock after abdominal section, 685 

differentiation from hemorrhage, 685 
treatment, 686 
Silk, sterilization of, 51 
Silkworm-gut, 307 

sterilization of, 52 
Simon's method of examination, 38 
Simpson's sound, 30 

Sims's operation for anterior colporrhaphy, 
338 
for colporrhaphy, 323 
position, 19 

in posterior vaginal section, 398 
sound, 30 
speculum, 35 
uterine elevator, 32 
Sinus from a neglected pelvic abscess, 

517 
Sound, uterine, 30 

dangers of, 31 
introduction of, 30 
replacement of uterus with, 288 
uses of, 31, 290 

in diagnosis, 291 
in prolapse of uterus, 320 
Speculum, bivalve, 37 
examination by, 33 
Fergusson's, 36 
Goodell's, 36 
introduction of, 37 
Sims's, 36 



Sphincter ani, dilatation of, after hyster- 
ectomy, 510 
muscle in perineorrhaphy, 341, 342 
repair of, by flap-splitting 
method, 345 
rupture of, 248 
Sponges, sterilization of, 54 
Sterility, 111 

abnormalities of involution as causes 

of, 113 
artificial impregnation in, 116 
from catarrhal salpingitis, 436 
degeneration of the uterus as cause of, 

113 
diagnosis, 115 
displacements of the uterus as causes 

of, 1 13 
etiology, 111 

Fallopian tubes in, 112 
ovaries in, 111 
uterus in, 112 
vagina in, 114 
general state of the patient's health in, 

114 
obstruction theory of Sims, 272 
from occlusion of Fallopian tubes, 

472 
prognosis, 115 

as a symptom in elongation of cervix, 
332 
of interstitial salpingitis and ova- 
ritis, 460 
treatment, 115 

urethral caruncle as a cause of, 114 
of uterine origin, 272 
vaginitis as a cause of, 114 
Sterilization, 45 

of absorbent cotton, 54 
by boiling water, 45 
of catgut, 52 
chemical, 45 
of drains, 55 
of dressings, 54 
of gauze, 55 
of the hands, 48 
of instruments, 49 
of ligatures, 50 
of silk, 51 
of silkworm-gut, 52 
of sponges, 54 
by steam, 45 
of suture-materials, 50 
of towels, 55 
Stitches in abdominal wall after hyster- 

orrhaphy, 309 
Stitch-hole abscesses, 683 

treatment, 684 
Stoltz's operation for cystocele, 340 
Strangulation from pressure of cyst, 578 
Stricture of the ureter, 667 
of the urethra, 623 
causes, 623 
diagnosis, 523 
prognosis, 624 
symptoms, 623 
treatment, 624 



■14 



INDEX. 



Stump after removal of uterine appendages, 

501 
Subcutaneous infusion, 67 
Subinvolution, 227 
symptoms, 228 
treatment, 228 
Suburethral abscess, 626 
cause, 626 
diagnosis, 626 
symptoms, 626 
treatment, 626 
Suction apparatus, 609 
Suppression of menses, 86 
Supravaginal hysterectomy, 405 
Sutures in Alexander's operation, 305 
in bladder-wound, 657 
catgut, in anterior colporrhaphy, 339 
in high amputation, 375 
in hysterorrhaphy, 308 
in Stoltz's operation, 341 
in colpo-perineorrhaphy, 341 
continuous, 339 
after enucleation of interstitial myoma, 

405 
in flap-splitting operation, 346 
in Freuud's operation for prolapse, 325 
interrupted, 342 
preparation of, 50 
silk, 305, 306 

thread, 334 
silkworm-gut, 306, 329, 346, 501 
silver-wire, 324 

in Sims's anterior colporrhaphy, 339 
in ventral hernia, 692 
in wedge-shaped amputation of cervix, 

337 

whipped silk, 406 

Syndroma menstrualis, 81 

Syphilis of the vulva, 162 

Syringe, uterine, 212 

Tait's operation for artificial menopause, 

519 
Tampon of the uterus, 213 

of the vagina in amputation of the 
cervix, 338 
in pelvic inflammation, 482 
in perineorrhaphy, 343 
in posterior vaginal section, 472 
in reposition, 298 
Tear, cervical, 231 

of the recto-vaginal septum, old, 239 
recent, 239 
Technique of abdominal operations, 60 
of gynecologic operations, 43 
of vaginal operations (not opening the 
peritoneal cavity), 58 
(in which the peritoneal cavity 
is opened), 65 
Thiersch's operation, 631 
Third ovary, 513 

Thomas's operation for inversion, 351 
Total extirpation of the uterus, 410 
Towels, sterilization of, 55 
Trachelorrhaphy, 323 
Trendelenburg position* 20, 307, 656 



Trocar in ovariotomy, 595 
Tubal abortion, 525 
anomalies, 544 
gestation, varieties, 519 
mole, 528 
pregnancy, 518 

changes in ovum in, 528 
diagnosis, 532 

differential, 536 
periods in treatment, 538 
physical signs in, 530 
rupture of, 540 

with fetal life continuing, 542 
symptoms, 529 
Tuberculosis of the bladder, 649 

bacilli in the urine in, 650 
diagnosis, 650 
pathological anatomy, 649 
symptoms, 650 
treatment, 651 
of the cervix uteri, 135 
of the Fallopian tubes, 139 
of the ovary, 142 
of- the peritoneum, 142 
caseous, 147 
course, 148 
diagnosis, 149 
prognosis, 150 
symptoms, 148 
treatment, 150 
fibroid, 145 

diagnosis, 146 
prognosis, 146 
symptoms, 145 
treatment, 146 
miliary, 143 

diagnosis, 144 
prognosis, 144 
symptoms, 143 
treatment, 144 
of the ureter, 664 
diagnosis, 664 
symptoms, 664 
treatment, 664 
of the uterus, 137 
diagnosis, 138 
symptoms, 138 
treatment, 138 
of the vagina, 135 
treatment, 136 
of the vulva, 132 
diagnosis, 133 
treatment, 133 
Tubo-ovarian cyst, 561 
Tubo-peritoneal ectopic gestation, 524 
Tubo-uterine pregnancy, 525 
Tumor, abdominal, adhesions of, 591 
exploratory puncture of, 592 
pedicle of, 591 
treatment, 593 
cystic, 590 

diagnosis 590 
desmoid, 588 
fecal, 589 

malignant, of the vulva, 355 
symptoms, 356 



INDEX. 



715 



Tumor of the ovary, adhesions of, 575 

diagnosis, 581 

inflammation of, 574 

solid, 569 

suppuration of, 574 

symptoms, 575 

torsion of pedicle of, 576 
phantom, 586 
Tympanites, 589 

Ulceration of the recto-vaginal septum 

in carcinoma, 369 
Unilocular cyst, 563 
Upright position, 20 
Urachus, patulous, 629 
Uremia from carcinoma, 370 

from ligature of ureter in operation, 697 
Ureter, anomalies of, 658 
treatment, 658 
bladder-implantation of, 660 
calculus of, 664 
diagnosis, 665 
symptoms, 665 
treatment, 666 
carcinoma of, 668 
catheterization of, 667 
changes in wall of, causing obstruction, 

667 
course of, marked on abdomen, 618 
cysts of, 669 
direct palpation of, 618 
diseases of, 608, 658 

preparation of patient in treatment 
of, 611 
examination of, direct, 616 

indirect, 616 
foreign bodies in, 664 
incision into, methods of, 666 
injuries of, in ovariotomy, 604 
ligation of, during operation, after- 
treatment in, 697, 698 
neoplasms of, 669 
obstruction of, 664 

by changes in wall of, 667 
diagnosis, 667 
symptoms, 667 
treatment, 668 
by outside pressure, 668 
symptoms, 668 
treatment, 668 
pelvic portion of, viewed from above, 
617 
viewed from below, 616 
relation of, to cervix, 408 
renal calculus in, 664 
sarcoma of, 669 
stricture of, 617 

treatment, 668 

tuberculosis of, 664 

diagnosis, 694 

symptoms, 664 

treatment, 664 

vaginal palpation of, 22 

wounds of, 658 

symptoms, 654 
treatment, 659, 660 



Ureteral calculus, 665 
diagnosis, 655 
symptoms, 665 
treatment, 666 
catheter, 612 
fistula, 257 

diagnosis, 258 
suture of, 259 
treatmeot, 258 
searcher, 610 
Ureteritis, 662 
diagnosis, 663 
etiology, 662 

pathological anatomy, 662 
symptoms, 663 
treatment, 663 
Uretero-ureteral anastomosis, stitches in, 659 
Uretero-vaginal fistula, 259 
Urethra, absence of, complete, 618 
partial, 619 
atresia of, 619 

treatment, 619 
carcinoma of, 356 

treatment, 356 
dilatation of, 41 
in cystitis, 548 
partial, 622 

causes, 622 
diagnosis, 622 
forms of, 622 
symptoms, 622 
treatment, 623 
total, 621 

causes, 621 
diagnosis, 621 
symptoms, 621 
treatment, 621 
diseases of, 618 

preparation of patient in treat- 
ment of, 611 
examination of, with cystoscope, 613 
palpation of, 615 
prolapse of bladder through a patulous, 

632 
stricture of, 623 
causes, 623 
diagnosis, 623 
prognosis, 624 
symptoms, 623 
treatment, 624 
Urethral caruncle, 627 
symptoms, 627 
treatment, 627 
catheter, 610 
condyloma, 627 
cause, 627 
diagnosis, 627 
symptoms, 627 
treatment, 628 
cysts, 628 

cause, 628 
symptoms, 628 
treatment, 628 
diverticulum, 626 
fever, 639 
fistula, 265 



71( 



INDEX. 



Urethral fistula, artificial, 265 
mucosa, prolapse of, 620 
cause, 620 
diagnosis, 620 
symptoms, 620 
treatment, 620 
neoplasms, 627 
orifice, searching for, 612 
polypi, 628 

treatment, 628 
Urethritis, 624 
causes, 624 

gonorrheal, diagnosis, 625 
symptoms, 625 
treatment, 625 
symptoms, 624 
tubercular, symptoms, 625 
Urine in after-treatment of operation, 677 
Uterine appendages, changes following re- 
moval of, 516 
operation for removal of, 494 
procedure for removal of, 497 
removal of, accidents in, 500 

Trendelenburg position in, 495 
applications, 203 
applicators, 34 

arteries, relation of, to the cervix, 408 
colic, 102 
elevator, 32 

Byford's, 33 
Sims's, 33 
hemorrhage, 93 

treatment, 95 
neoplasms, benign, 387 
secretion, 192 
sounds, 30 

dangers of, 31 
introduction of, 30 
uses of, 31 
syringe, 212 
Uterus, abnormalities of position of, 125 
absence of, 125 
adenoma of, benign, 196 
malignant, 378 
papillary, 197 
adhesions of, in pelvic peritonitis, 465 

separation of, 445 
amputation of, by Baldv's operation, 

327 
anteflexion of, forms of, 268 

pathology, 269 
applications to, 203 
bicornis, 126, 127 

diagnosis of, from abdominal cvst, 
584 
bimanual palpation of, 26 

recto-vaginal palpation of, 28 
carcinoma of the body of, 378 
diagnosis, 380 
probability of return after 

removal, 382 
symptoms, 379 
treatment, 381 
cervix of, amputation of, 373 

after-treatment, 338, 376 
by galvano-cautery, 375 



Uterus, cervix of, amputation of, high, 373 
procedure in, 374 
simple, 333 

vaginal, in inversion, 352 
wedge-shaped, 335 
curettage of, 210, 297 
and cystic ovary, removed by hemisec- 

tion, 511 
decidua expelled from, from ectopic 
gestation, 533 
photomicrograph of, 535 
didelphys, 129 
dilatation of, gradual, 40 

rapid, 40 
displacements of, 268 
distortions of, 268 
duplex, 129 
fibroid of, 389 

calcareous degeneration of, 392 

classification, 389 

complicated by ectopic gestation, 

534 
complications met during hyster- 
ectomy for, 417 
diagnosis, 396 

general considerations in, 418 
general symptoms, 396 
hemorrhage in, 395 
interstitial, 391, 392 
intraligamentous, 398 
nodular, 394, 403 
pain in, 394, 399 
pathology, 389 
pedunculated, 393 
polyp of, 387 

symptoms, 388 
treatment, 388 
pressure-symptoms in, 395 
removal by morcellation of, 402 
reposition of bladder in, 298 
submucous, 397 

subperitoneal pedunculated, 391 
subserous, method of removal of, 

404 
summary of treatment, 402 
symptoms, 394 
treatment, 400 

by electricity, 401 
by ergot, 400 
surgical, 402 
fibro- myoma of, 389 

interstitial, diagnosis, 397 
subserous, diagnosis, 398 
fibro-sarcoma of, 361 

svmptoms, 363 
glandular polyp of, 198 
growths within the, 585 
in hematosalpinx and hydrosalpinx, 

456 
inflammatory diseases of, 190 
intra-abdominal pressure in normal 

position of, 316 
inversion of, 347 
causes, 347 
diagnosis, 348 
prognosis, 349 






INDEX. 



717 



Uterus, inversion of, symptoms, 347 

treatment, 349 
malpositions of, 268 
morbid collections within the, 585 
myomata of, complicating ovarian 

cyst, 587 
packing of, 298 

with iodoform gauze, 338 
pathological anteflexion of, 268 
in posterior vaginal section, 469 
prolapse of, 310 

acute, 309 

causes, 310, 311, 313 

chronic, 319 

complete, 311 

cousequences of, 312 

diagnosis, 320 

mesial section of, 312 

pathology, 312 

prognosis, 321 

retroposition in, 318 

symptoms, 319 

treatment, 321 

varieties, 311 
rapid dilatation of, 40 
rectal palpation of, 25 
reposition of, Sims's position in, 289 
rudimentary, 125 
sarcoma of," 361 

causes, 362 

diagnosis, 364 

diffuse, symptoms, 363 

prognosis, 365 

symptoms, 363 

treatment, 366 
secretion of, 193 

separation of, from bladder in hyster- 
ectomy, 412 
septus, 128 
tamponade of, 213 
tuberculosis of, ]37 

diagnosis, 138 

symptoms, 138 

treatment, 138 
unicornis, 125 

ventro-recto-vaginal reduction of, in 
retrodisplacement, 281 

Vagina, absence of, 122, 124 
atresia of, 176 

course, 177 

diagnosis, 178 

prognosis, 180 

symptoms, 178 

treatment, 160 

varieties, 177 
carcinoma of, 358 

diagnosis, 358 

etiology, 358 

operative treatment, 359 

palliative treatment, 359 

symptoms, 358 
cysts of, 188 
douches of, 186, 187 
drainage through, for pelvic abscess. 408 
enucleation of fibroid by way of, 428 



Vagina, epithelioma of, 358 
etiology, 358 
fibroids of, 189 
inflammation of, 182 
irrigation of, 186 
malignant disease of, 357 
neoplasms of, 188 
non-malignant tumors of, 152 
papillary excrescences of, 189 
sarcoma of, 357 
diagnosis, 357 
prognosis, 358 
treatment, 358 
section of, posterior, 468 
sensitiveness of, 173 
tampon of, in amputation of the cervix, 
338 
in pelvic inflammation, 482 
in perineorrhaphy, 343 
in posterior vaginal section, 472 
in reposition, 298 
tuberculosis of, 134 
Vaginal amputation of cervix in inversion, 
352 
douches, 478 

drainage of pelvic abscess, 488 
entrance, examination of, 29 
enucleation of fibroid of uterus, 402 
examination, 21 
hysterectomy, 502 
dangers of, 513 
hemisection in, 511 
instruments in, 512 
for large uterus, 511 
operations (in which the peritoneal 
cavity is opened), 65 
(not opening the peritoneal cavity), 
technic of, 58 
outlet, relaxation of, in the dorsal posi- 
tion, 240 
in the Sims position, 341 
virginal, 238 
plug, 175 

puncture in treatment of pelvic ab- 
scess, 490 
section, after-treatment, 670 
posterior, 468 

procedure in, 468 
Vaginismus, 174 
Vaginitis, 182 
diagnosis, 185 
emphysematous, 184 
etiology, 182 
follicular, 185 
gonorrheal, 183 
granular, 184 
pathology, 183 
prognosis, 185 
simple, 183 
symptoms, 185 
treatment, 185 
varieties, 183 
vesicular, 184 
Varicose veins of the vulva, 165 
Vegetations of the vulva, 162 
Venereal warts of the vulva, 163 






718 



INDEX. 



Ventral hernia, 588 

after celiotomy, 691 
Ventro-suspension of uterus, 387 
Vesical calculus, 634 
diagnosis, 637 
etiology, 635 
prognosis, 638 
symptoms, 636 
treatment, 638 
varieties, 635 
fistula, 259 
Vesico-uterine fistula, 260 

treatment, 260 
Vesico-utero-vaginal fistula, 262 
Vesico-vaginal fistula, 262 

in treatment of cancer of urethra, 

356 
treatment, 263 
Vicarious menstruation, 82 
Villi, chorionic, in ectopic gestation, 538 
Virginal vaginal outlet, 238 
Viscera, injuries of, in ovariotomy, 603 
Volvulus after ovariotomy, 606 
Vomiting after operation, 671 
Vulva, absence of, 122 
carcinoma of, 355 
chancre of, 163 
chancroid of, 163 
cysts of, 169 
diphtheria of, 160 
eczema of, 159 
elephantiasis of, 168 
erysipelas of, 160 
exanthemata of, 158 
fibroids of, 169 



Vulva, gonorrhea of, 162 

hematoma of, 164 

herpes of, 158 

inflammation of, 154 

injuries of, 163 

lipoma of, 171 

non-malignant tumors of, 152 

prurigo of, 159 

pruritus of, 160 

scirrhous carcinoma, sarcoma, and me- 
dullary sarcoma of, 355 

specific diseases of, 162 

syphilitic affections of, 162 

tuberculosis of, 132 

tumors of, 168 

varicose veins of, 165 

vegetations of, 162 

venereal warts of, 163 
Vulvitis, 154 

follicular, 156 

gonorrheal, 162 

purulent, 155 

simple, 155 
Vulvo-vaginal glands, inflammation of, 
157 

hyperesthesia, 173 

Waldeyer's frozen section of pelvis, 290 
Wall of abdomen, fatty, 588 
Wedge-shaped amputation of cervix, 335 
Wylie's or Baer's operation, 299 

Xenomenia, 82 

Zinc-chloride pencils, 202 



CATALOGUE 

OF THE 

MEDIGAL PUBLICATIONS 

OF 

W. B. SAUNDERS, 

No. 925 WALNUT STREET, PHILADELPHIA. 



Arranged Alphabetically and Classified under Subjects. 



' I 'HE books advertised in this Catalogue as being sold by subscription are usually to be 
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See pages 30, 31, for a List of Contents classified according to subjects. 



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American Text-Book of Genito-Urinary and Skin Diseases. Page 4. 

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American Text-Book of Gynecology — Revised Edition. See page 4. 

American Year-Book of Medicine and Surgery. See page 6. 

Anders' Practice of Medicine — Revised Edition. See page 6. 

Vierordt's Medical Diagnosis — Fourth (Revised) Edition. See page 28. 

Van Valzah and Nisbet's Diseases of the Stomach. See page 28. 

Church and Peterson's Nervous and Mental Diseases. See page 9. 

Da Costa's Surgery — Revised and Enlarged Edition. See page JO. 

Saunders' Medical Hand-Atlases. See page 2. 

Saunders' Pocket Formulary — Fifth (Revised) Edition. See page 24. 

Keen's Surgical Complications of Typhoid Fever. See page J5. 

Griffith on The Baby — Revised Edition. See page 12. 

Butler's Materia Medica and Therapeutics — Revised Edition. Page 8. 

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De Schweinitz' Diseases of the Eye — Revised Edition. See page 10. 

Chapin's Compendium of Insanity. See page 8. 

Senn's Genito-Urinary Tuberculosis. See page 25. 

Penrose's Diseases of "Women. See page 18. 

McFarland's Pathogenic Bacteria — Revised Edition. See page 17. 

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" This is the most sumptuously illustrated work on midwifery that has yet appeared. In 
the number, the excellence, and the beauty of production of the illustrations it far surpasses 
every other book upon the subject. This feature alone makes it a work which no medical 
library should omit to purchase." — British Medical Journal. 

" As an authority, as a book of reference, as a ' working book ' for the student or prac- 
titioner, we commend it because we believe there is no better." — American Journal of the 
Medical Sciences. 



Illustrated Catalogue of the "American Text-Books " sent free upon application. 



Medical Publications of W. B. Saunders. 5 

AN AMERICAN TEXT=BOOK OF PATHOLOGY. 

Edited by John Guiteras, M.D., Professor of General Pathology and 
of Morbid Anatomy in the University of Pennsylvania ; and David 
Riesman, M.D., Demonstrator of Pathological Histology in the 
University of Pennsylvania. In Preparation. 

AN AMERICAN TEXT=BOOK OF PHYSIOLOGY. 

By 10 of the Leading Physiologists of America. Edited by William 
H. Howell, Ph.D., M.D., Professor of Physiology in the Johns Hop- 
kins University, Baltimore, Md. One handsome imperial octavo 
volume of 1052 pages. Illustrated. Cloth, 56.00 net; Sheep or Half 
Morocco, 57.00 net. Sold by Subscription. 

" We can commend it most heartily, not only to all students of physiology, but to every 
physician and pathologist, as a valuable and comprehensive work of reference, written by 
men who are of eminent authority in their own special subjects." — London Lancet. 

" To the practitioner of medicine and to the advanced student this volume constitutes, 
we believe, the best exposition of the present status of the science of physiology in the 
English language." — American Journal of the Medical Sa 



AN AMERICAN TEXT=BOOK OF SURGERY. Second Edition. 

By 13 Eminent Professors of Surgery. Edited by William W. Keen, 
M.D., LL.D., and J. William White, M.D., Ph.D. Handsome 
imperial octavo volume of 1250 pages, with 500 wood-cuts in the text, 
and 39 colored and half-tone plates. Thoroughly revised and enlarged, 
with a section devoted to " The Use of the Rontgen Rays in Surgery." 
Cloth, $7.00 net; Sheep or Half Morocco, $8. 00 net. Sold by Sub- 
scription. 

" Personally, I should not mind it being called THE Text-Book (instead of A Text- 
Book) , for I know of no single volume which contains so readable and complete an account 
of the science and art of Surgery as this does." — Edmund Owen, F.R.C.S. , Member of 
the Board of Examiners of the Royal College of Surgeons, England. 

" If this text-book is a fair reflex of the present position of American surgery, we must 
admit it is of a very high order of merit, and that English surgeons will have to look very 
carefully to their laurels if they are to preserve a position in the van of surgical practice." — 
London Lancet. 

AN AMERICAN TEXT=BOOK OF THE THEORY AND PRACTICE 
OF MEDICINE. 

By 12 Distinguished American Practitioners. Edited by Williaa 
Pepper, M.D., LL.D., Professor of the Theory and Practice of Medr 
cine and of Clinical Medicine in the University of Pennsylvania. Two 
handsome imperial octavo volumes of about 1000 pages each. Illus- 
trated. Prices per volume : Cloth, 55- 00 net ; Sheep or Half Morocco 
56.00 net. Sold by Subscription. 

" I am quite sure it will commend itself both to practitioners and students of medicine 
and become one of our most popular text-books." — Alfred Loomis, M.D., LL.D., Pro- 
fessor of Pathology and Practice of Medicine, University of the City of New York. 

"We reviewed the first volume of this work, and said : ' It is undoubtedly one of the 
best text-books on the practice of medicine which we possess.' A consideration of the 
second and last volume leads us to modify that verdict and to say that the completed work 
is in our opinion the best of its kind it has ever been our fortune to see." — A r ew York Medical 
Journal. 

Illustrated Catalogue of the "American Text-Books" sent free upon application. 



6 Medical Publications of W. B. Saunders. 

AN AMERICAN YEAR-BOOK OF MEDICINE AND SURGERY. 

A Yearly Digest of Scientific Progress and Authoritative Opinion in all 
branches of Medicine and Surgery, drawn from journals, monographs, 
and text-books of the leading American and Foreign authors and 
investigators. Collected and arranged, with critical editorial com- 
ments, by eminent American specialists and teachers, under the general 
editorial charge of George M. Gould, M.D. One handsome imperial 
octavo volume of about 1200 pages. Uniform in style, size, and 
general make-up with the "American Text-Book" Series. Cloth, 
$6.50 net ; Half Morocco, $7.50 net. Sold by Subscription. 

" It is difficult to know which to admire most — the research and industry of the distin- 
guished band of experts whom Dr. Gould has enlisted in the service of the Year-Book, or the 
wealth and abundance of the contributions to every department of science that have been 
deemed worthy of analysis. . . . It is much more than a mere compilation of abstracts, 
for, as each section is entrusted to experienced and able contributors, the reader has the 
advantage of certain critical commentaries and expositions . . . proceeding from writers 
fully qualified to perform these tasks. . . . It is emphatically a book which should find 
a place in every medical library, and is in several respects more useful than the famous 
'Jahrbiicher' of Germany." — London Lancet. 

ANDERS' PRACTICE OF MEDICINE. Second Edition. 

A Text-Book of the Practice of Medicine. By James M. Anders, 
M.D., Ph.D., LL.D., Professor of the Practice of Medicine and of 
Clinical Medicine, Medico- Chirurgical College, Philadelphia. In one 
handsome octavo volume of 1287 pages, fully illustrated. Cloth, 
$5.50 net; Sheep or Half Morocco, $6.50 net. 

"It is an excellent book, — concise, comprehensive, thorough, and up to date. It is a 
credit to you ; but, more than that, it is a credit to the profession of Philadelphia — to us." 
James C. Wilson, Professor of the Practice of Medicine and Clinical Medicine, Jefferson 
Medical College, Philadelphia. 

" I consider Dr. Anders' book not only the best late work on Medical Practice, but by 
far the best that has ever been published. It is concise, systematic, thorough, and fully up 
to date in everything. I consider it a great credit to both the author and the publisher." — 
A. C. COWPERTHWAITE, President of the Illinois Hotneopathic Medical Association. 

ASHTON'S OBSTETRICS. Fourth Edition, Revised. 

Essentials of Obstetrics. By W. Easterly Ashton, M.D., Pro- 
fessor of Gynecology in the Medico-Chirurgical College, Philadelphia. 
Crown octavo, 252 pages; 75 illustrations. Cloth, $1.00; interleaved 
for notes, $1.25. 

[See Sawiders' Question- Compends, page 21.] 
" Embodies the whole subject in a nut-shell. We cordially recommend it to our read- 
ers." — Chicago Medical Times. 

BALL'S BACTERIOLOGY. Third Edition, Revised. 

Essentials of Bacteriology ; a Concise and Systematic Introduction 
to the Study of Micro-organisms. By M. V. Ball, M.D., Bacteriol- 
ogist to St. Agnes' Hospital, Philadelphia, etc. Crown octavo, 218 
pages; 82 illustrations, some in colors, and 5 plates. Cloth, #1.00; 
interleaved for notes, #1.25. 

[See Saunders 1 Question- Compends, page 21.] 

" The student or practitioner can readily obtain a knowledge of the subject from a perusal 
of this book. The illustrations are clear and satisfactory." — Medical Record, New York. 



Medical Publications of W. B. Saunders. 7 

BASTIN'S BOTANY. 

Laboratory Exercises in Botany. By Edsox S. Bastin, M.A., 
late Professor of Materia Medica and Botany, Philadelphia College of 
Pharmacy. Octavo volume of 536 pages, with 87 plates. Cloth, $2.50. 

"It is unquestionably the best text-book on the subject that has yet appeared. The 
work is eminently a practical one. We regard the issuance of this book as an important 
event in the history of pharmaceutical teaching in this country, and predict for it an unquali- 
fied success." — Alumni Report to the Philadelphia College of Pharmacy. 

" There is no work like it in the pharmaceutical or botanical literature of this country, 
and we predict for it a wide circulation." — American Journal of Pharmacy. 

BECK'S SURGICAL ASEPSIS. 

A Manual of Surgical Asepsis. By Carl Beck, M.D., Surgeon to 
St. Mark's Hospital and the New York German Poliklinik, etc. 306 
pages; 65 text-illustrations, and 12 full-page plates. Cloth, $1.25 net. 

" An excellent exposition of the ' very latest ' in the treatment of wounds as practised 
by leading German and American surgeons." — Birmingham (Eng.) Medical Review. 

"This little volume can be recommended to any who are desirous of learning the details 
of asepsis in surgery, for it will serve as a trustworthy guide." — London Lancet. 

BOISLINIERE'S OBSTETRIC ACCIDENTS, EMERGENCIES, AND 
OPERATIONS. 
Obstetric Accidents, Emergencies, and Operations. By L. Ch. 

Boislixiere, M.D., late Emeritus Professor of Obstetrics, St. Louis 
Medical College. 381 pages, handsomely illustrated. Cloth, $2.00 net. 

" It is clearly and concisely written, and is evidently the work of a teacher and practi- 
tioner of large experience." — British Medical Journal. 

" A manual so useful to the student or the general practitioner has not been brought to 
our notice in a long time. The field embraced in the title is covered in a terse, interesting 
way." — -Yale Medical Journal. 

BROCKWAY'S MEDICAL PHYSICS. Second Edition, Revised. 
Essentials of Medical Physics. By Fred J. Brockway, M.D., 
Assistant Demonstrator of Anatomy in the College of Physicians and 
Surgeons, New York. Crown octavo, 330 pages; 155 fine illustrations. 
Cloth, Si-oo net ; interleaved for notes, $1.25 net. 

[See Saunders' 1 Question- Compends, page 21.] 

" The student who is well versed in these pages will certainly prove qualified to com- 
prehend with ease and pleasure the great majority of questions involving physical principles 
likely to be met with in his medical studies." — American Practitioner and News. 

"We know of no manual that affords the medical student a better or more concise 
exposition of physics, and the book may be commended as a most satisfactory presentation 
of those essentials that are requisite in a course in medicine." — New York Medical Journal. 

" It contains all that one need know on the subject, is well written, and is copiously 
illustrated." — Medical Record, New York. 

BURR ON NERVOUS DISEASES. 

A Manual of Nervous Diseases. By Charles W. Burr, M.D., 
Clinical Professor of Nervous Diseases, Medico-Chirurgical College, 
Philadelphia ; Pathologist to the Orthopedic Hospital and Infirmary 
for Nervous Diseases; Visiting Physician to St. Joseph's Hospital, etc. 
Jn Preparation. 



8 Medical Publications of W. B. Saunders. 

BUTLER'S MATERIA MEDICA, THERAPEUTICS, AND PHAR- 
MACOLOGY. Second Edition, Revised. 
A Text=Book of Materia Medica, Therapeutics, and Pharma= 
cology. By George F. Butler, Ph.G., M.D., Professor of Materia 
Medica and of Clinical Medicine in the College of Physicians and 
Surgeons, Chicago; Professor of Materia Medica and Therapeutics, 
Northwestern University, Woman's Medical School, etc. Octavo, 860 
pages, illustrated. Cloth, $4.00 net; Sheep, $5.00 net. 

" Taken as a whole, the book may fairly be considered as one of the most satisfactory 
of any single-volume works on materia medica in the market," — Journal of the American 
Medical Association. 

"The work is executed in a clear, concise, and practical manner, and should meet with 
a hearty endorsement from the students of our up-to-date colleges. The book will be found 
a valuable work of teference for the practitioner." — American Medico-Surgical Bulletin. 

CASSELBERRY ON THE NOSE AND THROAT. 

Diseases of the Nose and Throat. By W. E. Casselberry, Pro- 
fessor of Laryngology and Rhinology in the Northwestern University 
Medical School, Chicago. In Preparation. 

CERNA ON THE NEWER REMEDIES. Second Edition, Revised. 
Notes on the Newer Remedies, their Therapeutic Applications 
and Modes of Administration. By David Cerna, M.D., Ph.D., 
formerly Demonstrator of and Lecturer on Experimental Therapeutics 
in the University of Pennsylvania ; Demonstrator of Physiology in the 
Medical Department of the University of Texas. Rewritten and 
greatly enlarged. Post-octavo, 253 pages. Cloth, $1.25. 

" The appearance of this new edition of Dr. Cerna's very valuable work shows that it 
is properly appreciated. The book ought to be in the possession of every practising physi- 
cian." — New York Medical Journal. 

CHAPIN ON INSANITY. 

A Compendium of Insanity. By John B. Chapin, M.D., LL.D., 
Physician-in-Chief, Pennsylvania Hospital for the Insane ; late Physi- 
cian-Superintendent of the Willard State Hospital, New York ; Hon- 
orary Member of the Medico-Psychological Society of Great Britain, 
of the Society of Mental Medicine of Belgium. i2mo, 234 pages, 
illustrated. Cloth, $1.25 net. 

The author has given, in a condensed and concise form, a compendium of Diseases of 
the Mind, for the convenient use and aid of physicians and students. The work will also 
prove valuable to members of the legal profession and to those who, in their relations to the 
insane and to those supposed to be insane, often desire to acquire some practical knowledge 
of insanity presented in a form that may be understood by the non-professional reader. 

CHAPMAN'S MEDICAL JURISPRUDENCE AND TOXICOLOGY. 
Second Edition, Revised. 
Medical Jurisprudence and Toxicology. By Henry C. Chapman, 
M.D., Professor of Institutes of Medicine and Medical Jurisprudence 
in the Jefferson Medical College of Philadelphia. 254 pages, with 55 
illustrations and 3 full-page plates in colors. Cloth, $1.50 net. 
"The best book of its class for the undergraduate that we know of." — New York 
Medical Times. 



Medical Publications of W. B. Saunders. 9 

CHURCH AND PETERSON'S NERVOUS AND MENTAL DISEASES. 
Nervous and Mental Diseases. By Archibald Church, M.D., 
Professor of Mental Diseases and Medical Jurisprudence in the North- 
western University Medical School, Chicago ; and Frederick Peter- 
son, M.D., Clinical Professor of Mental Dii^ases in the Woman's 
Medical College, New York ; Chief of Clinic, Nervous Department, 
College of Physicians and Surgeons, New York. In Preparation. 

CLARKSON'S HISTOLOGY. 

A Text=Book of Histology, Descriptive and Practical. By 

Arthur Clarkson, M.B., CM. Edin., formerly Demonstrator of 
Physiology in the Owen's College, Manchester; late Demonstrator of 
Physiology in Yorkshire College, Leeds. Large octavo, 554 pages; 
22 engravings in the text, and 174 beautifully colored original illustra- 
tions. Cloth, strongly bound, $6.00 net. 

"The work must be considered a valuable addition to the list of available text- books, 
and is to be highly recommended." — New York Medical Journal. 

"This is one of the best works for students we have ever noticed. We predict that the 
book will attain a well-deserved popularity among our students." — Chicago Medical Recorder. 

"The volume is a most valuable addition to the armamentarium of the teacher." — 
Brooklyn Medical Journal. 

CLIMATOLOGY. 

Transactions of the Eighth Annual Meeting of the American 
Climatological Association, held in Washington, September 22-25, 
1891. Forming a handsome octavo volume of 276 pages, uniform with 
remainder of series. (A limited quantity only.) Cloth, $1.50. 

COHEN AND ESHNER'S DIAGNOSIS. 

Essentials of Diagnosis. By Solomon Solis-Cohen, M.D., Pro- 
fessor of Clinical Medicine and Applied Therapeutics in the Philadel- 
phia Polyclinic ; and Augustus A. Eshner, M.D., Professor of Clinical 
Medicine in the Philadelphia Polyclinic. Post-octavo, 382 pages; 55 
illustrations. Cloth, #1.50 net. 

[See Saunders' Question- Compends, page 21.] 

" We can heartily commend the book to all those who contemplate purchasing a 'com- 
pend.' It is modern and complete, and will give more satisfaction than many other works 
which are perhaps too prolix as well as behind the times." — Medical Review, St. Louis. 

CORWIN'S PHYSICAL DIAGNOSIS. 

Essentials of Physical Diagnosis of the Thorax. By Arthur 
M. Corwin, A.M., M.D., Demonstrator of Physical Diagnosis in Rush 
Medical College, Chicago ; Attending Physician to Central Free Dis- 
pensary, Department of Rhinology, Laryngology, and Diseases of the 
Chest, Chicago. 200 pages, illustrated. Cloth, flexible covers, $1.25 net. 

" It is excellent. The student who shall use it as his guide to the careful study of 
physical exploration upon normal and abnormal subjects can scarcely fail to acquire a good 
working knowledge of the subject." — Philadelphia Polyclinic. 

"A most excellent little work. It brightens the memory of the differential diagnostic 
signs, and it arranges orderly and in sequence the various objective phenomena to logical 
solution of a careful diagnosis." — Journal of Nervotis and Mental Diseases. 



10 Medical Publications of W. B. Saunders. 

CRAQIN'S GYNECOLOGY. Fourth Edition, Revised. 

Essentials of Gynaecology. By Edwin B. Cragin, M.D., Attend- 
ing Gynaecologist, Roosevelt Hospital, Out-Patients' Department, New 
York, etc. Crown octavo, 200 pages; 62 fine illustrations. Cloth, 
#1.00; interleaved for notes, #1.25. 

[See Saunders'' Question- Compends, page 21.] 

"A handy volume, and a distinct improvement on students' compends in general. No 
author who was not himself a practical gynecologist could have consulted the student's needs 
so thoroughly as Dr. Cragin has done." — Medical Record, New York. 

CROOKSHANK'S BACTERIOLOGY. Fourth Edition, Revised. 

A Text=Book of Bacteriology. By Edgar M. Crookshank, M.B., 
Professor of Comparative Pathology and Bacteriology, King's College, 
London. Octavo volume of 700 pages, with 273 engravings and 22 
original colored plates. Cloth, $6.50 net; Half Morocco, $7.50 net. 

" To the student who wishes to obtain a good resume of what has been done in bacteri- 
ology, or who wishes an accurate account of the various methods of research, the book may 
be recommended with confidence that he will find there what he requires." — London Lancet. 

Da COSTA'S SURGERY. Second Ed., Revised and Greatly Enlarged. 
Modern Surgery, General and Operative. By John Chalmers 
DaCosta, M.D., Clinical Professor of Surgery, Jefferson Medical 
College, Philadelphia; Surgeon to the Philadelphia Hospital, etc. 
Handsome octavo volume of 900 pages, profusely illustrated. Cloth, 
$4.00 net; Half Morocco, $5.00 net. 

"We know of no small work on surgery in the English language which so well fulfils 
the requirements of the modern student." — Medico- Chirurgical Journal, Bristol, England. 

DE SCHWEINITZ ON DISEASES OF THE EYE. Third Edition, 
Revised. 
Diseases of the Eye. A Handbook of Ophthalmic Practice. 

By G. E. de Schweinitz, M.D., Professor of Ophthalmology in the 
Jefferson Medical College, Philadelphia, etc. Handsome royal octavo 
volume of 700 pages, with 256 fine illustrations and 2 chromo-litho- 
graphic plates. Cloth, $4. 00 net ; Sheep or Half Morocco, $5.00 net. 

" A clearly written, comprehensive manual. One which we can commend to students 
as a reliable text-book, written with an evident knowledge of the wants of those entering 
upon the study of this special branch of medical science." — British Medical Journal. 

" A work that will meet the requirements not only of the specialist, but of the general 
practitioner in a rare degree. I am satisfied that unusual success awaits it." — William 
Pepper, M.D., Professor of the Theory and Practice of Medicine and Clinical Medicine, 
University of Pennsylvania. 

DORLAND'S OBSTETRICS. 

A Manual of Obstetrics. By W. A. Newman Dorland, M.D., 
Assistant Demonstrator of Obstetrics, University of Pennsylvania ; 
Instructor in Gynecology in the Philadelphia Polyclinic. 760 pages; 
163 illustrations in the text, and 6 full-page plates. Cloth, $2.50 net. 

"By far the best book on this subject that has ever come to our notice." — American 
Medical Review. 

" It has rarely been our duty to review a book which has given us more pleasure in its 
perusal and more satisfaction in its criticism. It is a veritable encyclopedia of knowledge, 
a gold mine of practical, concise thoughts." — American Medico-Surgical Bulletin. 



Medical Publications of W. B. Saunders. 11 

FROTHINGHAM'S GUIDE FOR THE BACTERIOLOGIST. 

Laboratory Guide for the Bacteriologist. By Langdon Froth- 
ingham, M.D.V., Assistant in Bacteriology and Veterinary Science, 
Sheffield Scientific School, Yale University. Illustrated. Cloth, 75 cts. 

" It is a convenient and useful little work, and will more than repay the outlay neces- 
sary for its purchase in the saving of time which would otherwise be consumed in looking 
up the various points of technique so clearly and concisely laid down in its pages." — Ameri- 
can Medico- Surgical Bulletin. 

GARRIGUES' DISEASES OF WOMEN. Second Edition, Revised. 
Diseases of Women. By Henry J. Garrigues, A.M., M.D., Pro- 
fessor of Gynecology in the New York School of Clinical Medicine; 
Gynecologist to St. Mark's Hospital and to the German Dispensary, 
New York City, etc. Handsome octavo volume of 728 pages, illus- 
trated by 335 engravings and colored plates. Cloth, $4.00 net; 
Sheep or Half Morocco, $5.00 net. 

" One of the best text-books for students and practitioners which has been published in 
the English language ; it is condensed, clear, and comprehensive. The profound learning 
and great clinical experience of the distinguished author find expression in this book in a 
most attractive and instructive form. Young practitioners to whom experienced consultants 
may not be available will find in this book invaluable counsel and help." — Thad. A. 
Reamy, M.D., LL.D., Professor of Cluneal Gynecology, Medical College of Ohio. 

GLEASON'S DISEASES OF THE EAR. Second Edition, Revised. 
Essentials of Diseases of the Ear. By E. B. Gleason, S.B., 
M.D., Clinical Professor of Otology, Medico-Chirurgical College, 
Philadelphia ; Surgeon-in-Charge of the Nose, Throat, and Ear Depart- 
ment of the Northern Dispensary, Philadelphia. 208 pages, with 
114 illustrations. Cloth, $1.00 ; interleaved for notes, $1.25. 
[See Saunders' Question- Compends, page 21.] 

" It is just the book to put into the hands of a student, and cannot fail to give him a 
useful introduction to ear-affections ; while the style of question and answer which is adopted 
throughout the book is, we believe, the best method of impressing facts permanently on the 
mind." — Liverpool Medico- Chintrgical Journal. 

GOULD AND PYLE'S CURIOSITIES OF MEDICINE. 

Anomalies and Curiosities of Medicine. By George M. Gould, 
M.D., and Walter L. Pyle, M.D. An encyclopedic collection of 
rare and extraordinary cases and of the most striking instances of 
abnormality in all branches of Medicine and Surgery, derived from an 
exhaustive research of medical literature from its origin to the present 
day, abstracted, classified, annotated, and indexed. Handsome im- 
perial octavo volume of 968 pages, with 295 engravings in the text, 
and 12 full-page plates. Cloth, $6.00 net; Half Morocco, $7.00 net. 
Sold by Subscription. 

" One of the most valuable contributions ever made to medical literature. It is, so far 
as we know, absolutely unique, and every page is as fascinating as a novel. Not alone for 
the medical profession has this volume value: it will serve as a book of reference for all who 
are interested in general scientific, sociologic, or medico-legal topics." — Brooklyn Medical 
Journal. 

"This is certainly a most remarkable and interesting volume. It stands alone among 
medical literature, an anomaly on anomalies, in that there is nothing like it elsewhere in 
medical literature. It is a book full of revelations from its first to its last page, and cannot 
but interest and sometimes almost horrify its readers." — American Medico- Surgical Bulletin. 



12 Medical Publications of W. B. Saunders. 

GRIFFIN'S MATERIA MEDICA AND THERAPEUTICS. 

Manual of Materia Medica and Therapeutics. By Henry A. 
Griffin, A.B. , M.D., Assistant Physician to the Roosevelt Hospital, 
Out-Patient Department, New York City. In Preparation. 

GRIFFITH ON THE BABY. Second Edition, Revised. 

The Care of the Baby. By J. P. Crozer Griffith, M.D., Clini- 
cal Professor of Diseases of Children, University of Pennsylvania ; 
Physician to the Children's Hospital, Philadelphia, etc. nmo, 404 
pages, with 67 illustrations in the text, and 5 plates. Cloth, $1.50. 

" The best book for the use of the young mother with which we are acquainted. . . . 
There are very few general practitioners who could not read the book through with advan- 
tage. ' ' — Archives of Pediatrics. 

"The whole book is characterized by rare good sense, and is evidently written by a 
master hand. It can be read with benefit not only by mothers but by medical students and 
by any practitioners who have not had large opportunities for observing children." — Ameri- 
can Journal of Obstetrics. 

GRIFFITH'S WEIGHT CHART. 

Infant's Weight Chart. Designed by J. P. Crozer Griffith, M. D. , 
Clinical Professor of Diseases of Children in the University of Penn- 
sylvania, etc. 25 charts in each pad. Per pad, 50 cents net. 

A convenient blank for keeping a record of the child's weight during the first two years 
of life. Printed on each chart is a curve representing the average weight of a healthy infant, 
so that any deviation from the normal can readily be detected. 

GROSS, SAMUEL D., AUTOBIOGRAPHY OF. 

Autobiography of Samuel D. Gross, M.D., Emeritus Professor of 
Surgery in the Jefferson Medical College, Philadelphia, with Remi- 
niscences of His Times and Contemporaries. Edited by his Sons, 
Samuel W. Gross, M.D., LL.D., late Professor of Principles of Sur- 
gery and of Clinical Surgery in the Jefferson Medical College, and 
A. Haller Gross, A.M., of the Philadelphia Bar. Preceded by a 
Memoir of Dr. Gross, by the late Austin Flint, M.D., LL.D. In 
two handsome volumes, each containing over 400 pages, demy octavo, 
extra cloth, gilt tops, with fine Frontispiece engraved on steel. Price 
per volume, $2.50 net. 

" Dr. Gross was perhaps the most eminent exponent of medical science that America 
has yet produced. His Autobiography, related as it is with a fulness and completeness 
seldom to be found in such works, is an interesting and valuable book. He comments on 
many things, especially, of course, on medical men and medical practice, in a very interest- 
ing way." — The Spectator, London, England. 

HAMPTON'S NURSING. 

Nursing: Its Principles and Practice. By Isabel Adams Hamp- 
ton, Graduate of the New York Training School for Nurses attached 
to Bellevue Hospital ; Superintendent of Nurses, and Principal of the 
Training School for Nurses, Johns Hopkins Hospital, Baltimore, Md. 
i2mo, 484 pages, profusely illustrated. Cloth, $2.00 net. 

" Seldom have we perused a book upon the subject that has given us so much pleasure 
as the one before us. We would strongly urge upon the members of our own profession the 
need of a book like this, for it will enable each of us to become a training school in him- 
self. ' ' — Ontario Medical Journal. 






Medical Publications of W. B. Saunders. 13 

HARE'S PHYSIOLOGY. Third Edition, Revised. 

Essentials of Physiology. By H. A. Hare, M.D., Professor of 
Therapeutics and Materia Medica in the Jefferson Medical College of 
Philadelphia; Physician to the Jefferson Medical College Hospital. 
Containing a series of handsome illustrations from the celebrated 
" Icones Nervorum Capitis" of Arnold. Crown octavo, 239 pages. 

* Cloth, $1.00 net; interleaved for notes, $1.25 net. 

[See Saunders' Question- Compends, page 21.] 

"The best condensation of physiological knowledge we have yet seen." — Medical 
Record, New York. 

HART'S DIET IN SICKNESS AND IN HEALTH. 

Diet in Sickness and in Health. By Mrs. Ernest Hart, formerly 
Student of the Faculty of Medicine of Paris and of the London School 
of Medicine for Women ; with an Introduction by Sir Henry 
Thompson, F. R. C. S. , M. D. , London. 220 pages ; illustrated. Cloth, 
$1.50. 

" We recommend it cordially to the attention of all practitioners ; both to them and to 
their patients it may be of the greatest service." — New York Medical Journal. 

HAYNES' ANATOMY. 

A Manual of Anatomy. By Irving S. Haynes, M.D., Adjunct 
Professor of Anatomy and Demonstrator of Anatomy, Medical Depart- 
ment of the New York University, etc. 680 pages, illustrated with 42 
diagrams in the text, and 134 full-page half-tone illustrations from 
original photographs of the author's dissections. Cloth, $2.50 net. 

" This book is the work of a practical instructor — one who knows by experience the 
requirements of the average student, and is able to meet these requirements in a very satis- 
factory way. The book is one that can be commended." — Medical Record, New York. 

HEISLER'S EMBRYOLOGY. 

A Text=Book of Embryology. By John C. Heisler, M.D., Pro- 
fessor of Anatomy in the Medico-Chirurgical College, Philadelphia. 
In Preparation. 

HIRST'S OBSTETRICS. 

A Text=Book of Obstetrics. By Barton Cooke Hirst, M.D., 
Professor of Obstetrics in the University of Pennsylvania. In Prepa- 
ration. 

HYDE AND MONTGOMERY ON SYPHILIS AND THE VENEREAL 
DISEASES. 
Syphilis and the Venereal Diseases. By James Nevins Hyde, 
M.D., Professor of Skin and Venereal Diseases, and Frank H. Mont- 
gomery, M.D., Lecturer on Dermatology and Genito-Urinary Diseases 
in Rush Medical College, Chicago, 111. 618 pages, profusely illustrated. 
Cloth, $2.50 net. 

" We can commend this manual to the student as a help to him in his study of venereal 
diseases." — Liverpool Medico- Ckirurgical Journal. 

"The best student's manual which has appeared on the subject." — St. Louis Medica! 
and Surgical Journal. 



14 Medical Publications of W. B. Saunders. 

JACKSON AND GLEASON'S DISEASES OF THE EYE, NOSE, AND 
THROAT. Second Edition, Revised. 
Essentials of Refraction and Diseases of the Eye. By Edward 
Jackson, A.M., M.D., Professor of Diseases of the Eye in the Phila- 
delphia Polyclinic and College for Graduates in Medicine; and — 
Essentials of Diseases of the Nose and Throat. By E. Bald- 
win Gleason, M.D., Surgeon-in-Charge of the Nose, Throat, and 
Ear Department of the Northern Dispensary of Philadelphia. Two 
volumes in one. Crown octavo, 290 pages; 124 illustrations. Cloth, 
$1.00; interleaved for notes, #1.25. 

[See Saunders' Question- Compends, page 21.] 

" Of great value to the beginner in these branches. The authors are both capable men, 
and know what a student most needs." — Medical Record, New York. 

KEATING'S DICTIONARY. Second Edition, Revised. 

A New Pronouncing Dictionary of Medicine, with Phonetic 
Pronunciation, Accentuation, Etymology, etc. By John M. 
Keating, M.D., LL.D., Fellow of the College of Physicians of Phila- 
delphia ; Vice-President of the American Paediatric Society ; Editor 
" Cyclopaedia of the Diseases of Children," etc.; and Henry 
Hamilton, Author of "A New Translation of Virgil's ^Eneid into 
English Rhyme," etc.; with the collaboration of J. Chalmers Da- 
Costa, M.D., and Frederick A. Packard, M.D. With an Appendix 
containing Tables of Bacilli, Micrococci, Leucoma'ines, Ptomaines; 
Drugs and Materials used in Antiseptic Surgery ; Poisons and their 
Antidotes; Weights and Measures; Thermometric Scales; New 
Official and Unofficial Drugs, etc. One volume of over 800 pages. 
Prices, with Denison's Patent Ready-Reference Index: Cloth, $5.00 
net; Sheep or Half Morocco, $6.00 net; Half Russia, $6.50 net. 
Without Patent Index: Cloth, $4.00 net; Sheep or Half Morocco, 
$5.00 net. 

" I am much pleased with Keating's Dictionary, and shall take pleasure in recommend- 
ing it to my classes." — Henry M. Lyman, M.D., Professor of the Principles and Practice 
of Medicine, Rush Medical College, Chicago, III. 

" I am convinced that it will be a very valuable adjunct to my study-table, convenient 
in size and sufficiently full for ordinary use." — C. A. Lindsley, M.D., Professor of the 
Theory and Practice of Medicine, Medical Dept. Yale University. 

KEATING'S LIFE INSURANCE. 

How to Examine for Life Insurance. By John M. Keatino, 
M.D., Fellow of the College of Physicians of Philadelphia; Vice- 
President of the American Paediatric Society ; Ex-President of the 
Association of Life Insurance Medical Directors. Royal octavo, 211 
pages ; with two large half-tone illustrations, and a plate prepared by 
Dr. McClellan from special dissections ; also, numerous other illustra- 
tions. Cloth, $2.00 net. 

" This is by far the most useful book which has yet appeared on insurance examination, 
a subject of growing interest and importance. Not the least valuable portion of the volume 
is Part II, which consists of instructions issued to their examining physicians by twenty-four 
representative companies of this country. If for these alone, the book should be at the right 
hand of every physician interested in this special branch of medical science." — The Medical 
News. 



Medical Publications of W. B. Saunders. 15 

KEEN ON THE SURGERY OF TYPHOID FEVER. 

The Surgical Complications and Sequels of Typhoid Fever. 

By Wm. W. Keen, M.D., LL.D., Professor of the Principles of Sur- 
gery and of Clinical Surgery, Jefferson Medical College, Philadelphia; 
Corresponding Member of the Societe de Chimrgie, Paris ; Honorary 
Member of the Societe Beige de Chirurgie, etc. Octavo volume of 
386 pages, illustrated. Cloth, $3.00 net. 
This monograph is the only one in any language covering the entire subject of the 
Surgical Complications and Sequels of Typhoid Fever. It will prove to be of importance 
and interest not only to the general surgeon and physician, but also to many specialists — laryn- 
gologists, gynecologists, pathologists, and bacteriologists. 

KEEN'S OPERATION BLANK. Second Edition, Revised Form. 
An Operation Blank, with Lists of Instruments, etc. Required 
in Various Operations. Prepared by W. W. Keen, M.D., LL.D., 

Professor of the Principles of Surgery in Jefferson Medical College, 
Philadelphia. Price per pad, containing blanks for fifty operations, 
50 cents net. 

KYLE ON THE NOSE AND THROAT. 

Diseases of the Nose and Throat. By D. Braden Kyle, M.D., 
Clinical Professor of Laryngology and Rhinology, Jefferson Medical 
College, Philadelphia; Consulting Laryngologist, Rhinologist, and 
Otologist, St. Agnes' Hospital ; Bacteriologist to the Philadelphia 
Orthopedic Hospital. In Preparation. 

LAINE'S TEMPERATURE CHART. 

Temperature Chart. Prepared by D. T. Laine, M.D. Size 8x13^ 
inches. A conveniently arranged Chart for recording Temperature, 
with columns for daily amounts of Urinary and Fecal Excretions, 
Food, Remarks, etc. On the back of each chart is given in full the 
method of Brand in the treatment of Typhoid Fever. Price, per pad 
of 25 charts, 50 cents net. 

" To the busy practitioner this chart will be found of great value in fever cases, and 
especially for cases of typhoid." — Indian Lancet, Calcutta. 

LOCKWOOD'S PRACTICE OF MEDICINE. 

A Manual of the Practice of Medicine. By George Roe Lock- 
wood, M.D., Professor of Practice in the Woman's Medical College 
of the New York Infirmary, etc. 935 pages, with 75 illustrations in 
the text, and 22 full-page plates. Cloth, $2.50 net. 

" Gives in a most concise manner the points essential to treatment usually enumerated 
in the most elaborate works." — Massachusetts Medical Journal. 

LONG'S SYLLABUS OF GYNECOLOGY. 

A Syllabus of Gynecology, arranged in Conformity with •« An 
American Text=Book of Gynecology." By J. W. Long, M.D., 
Professor of Diseases of Women and Children, Medical College of 
Virginia, etc. Cloth, interleaved, $1.00 net. 

" The book is certainly an admirable resume of what every gynecological student and 
practitioner should know, and will prove of value not only to those who have the ' American 
Text-Book of Gynecology,' but to others as well." — Brooklyn Medical Journal. 



16 Medical Publications of W. B. Saunders. 

MACDONALD'S SURGICAL DIAGNOSIS AND TREATMENT. 

Surgical Diagnosis and Treatment. By J. W. Macdonald, M.D. 
Edin., L.R.C.S., Edin., Professor of the Practice of Surgery and of 
Clinical Surgery in Hamline University; Visiting Surgeon to St. 
Barnabas' Hospital, Minneapolis, etc. Handsome octavo volume of 
800 pages, profusely illustrated. Cloth, $5.00 net; Half Morocco, 
$6.00 net. 

" A thorough and complete work on surgical diagnosis and treatment, free from pad- 
ding, full of valuable material, and in accord with the surgical teaching of the day." — The 
Medical Nezvs, New York. 

" The work is brimful of just the kind of practical information that is useful alike to 
students and practitioners. It is a pleasure to commend the book because of its intrinsic 
value to the medical practitioner." — Cincinnati Lancet- Clinic. 

MALLORY AND WRIGHT'S PATHOLOGICAL TECHNIQUE. 

Pathological Technique. A Practical Manual for Laboratory Work 
in Pathology, Bacteriology, and Morbid Anatomy, with chapters on 
Post-Mortem Technique and the Performance of Autopsies. By Frank 
B. Mallory, A.M., M.D., Assistant Professor of Pathology, Harvard 
University Medical School, Boston; and James H. Wright, A.M., 
M.D., Instructor in Pathology, Harvard University Medical School, 
Boston. Octavo volume of 396 pages, handsomely illustrated. Cloth, 
#2.50 net. 

" I have been looking forward to the publication of this book, and I am glad to say that 
I find it to be a most useful laboratory and post-mortem guide, full of practical information, 
and well up to date." — William H. Welch, Professor of Pathology, Johns Hopkins Uni- 
versity, Baltimore, Md. 

MARTIN'S MINOR SURGERY, BANDAGING, AND VENEREAL 
DISEASES. Second Edition, Revised. 
Essentials of Minor Surgery, Bandaging, and Venereal 
Diseases. By Edward Martin, A.M., M.D., Clinical Professor of 
Genito-Urinary Diseases, University of Pennsylvania, etc. Crown 
octavo, 166 pages, with 78 illustrations. Cloth, $1.00; interleaved for 
notes, #1.25. 

[See Saunders' Question- Compends, page 21.] 

" A very practical and systematic study of the subjects, and shows the author's famil- 
iarity with the needs of students." — Therapetitic Gazette. 

MARTIN'S SURGERY. Sixth Edition, Revised. 

Essentials of Surgery. Containing also Venereal Diseases, Surgi- 
cal Landmarks, Minor and Operative Surgery, and a complete de- 
scription, with illustrations, of the Handkerchief and Roller Bandages. 
By Edward Martin, A.M., M.D., Clinical Professor of Genito- 
Urinary Diseases, University of Pennsylvania, etc. Crown octavo, 338 
pages, illustrated. With an Appendix containing full directions for the 
preparation of the materials used in Antiseptic Surgery, etc. Cloth, 
$1.00; interleaved for notes, #1.25. 

[See Saunders 1 Question- Compends, page 21.] 

" Contains all necessary essentials of modern surgery in a comparatively small space. 
Its style is interesting, and its illustrations are admirable." — Medical and Surgical Reporter. 



Medical Publications of W. B. Saunders. 17 

McFARLAND'S PATHOGENIC BACTERIA. Second Edition, Re= 
vised and Greatly Enlarged. 
Text=Book upcn the Pathogenic Bacteria. By Joseph McFar- 
land, M. D. , Professor of Pathology and Bacteriology in the Medico- 
Chirurgical College of Philadelphia, etc. Octavo volume of 497 pages, 
finely illustrated. Cloth, $2.50 net. 

"Dr. McFarland has treated the subject in a systematic manner, and has succeeded in 
presenting in a concise and readable form the essentials of bacteriology up to date. Alto- 
gether, the book is a satisfactory one, and I shall take pleasure in recommending it to the 
students of Trinity College." — H. B. ANDERSON, M.D. , Professor of Pathology and Bac- 
teriology, Trinity Medical College, Toronto. 

MEIGS ON FEEDING IN INFANCY. 

Feeding in Early Infancy. By Arthur V. Meigs, M.D. Bound 
in limp cloth, flush edges,_ 25 cents net. 

" This pamphlet is worth many times over its price to the physician. The author's 
experiments and conclusions are original, and have been the means of doing much good." — 
Medical Bulletin. 

MOORE'S ORTHOPEDIC SURGERY. 

A Manual of Orthopedic Surgery. By James E. Moore, M.D., 
Professor of Orthopedics and Adjunct Professor of Clinical Surgery, 
University of Minnesota, College of Medicine and Surgery. Octavo 
volume of 356 pages, handsomely illustrated. Cloth, $2.50 net. 

A practical book based upon the author's experience, in which special stress is laid 
upon early diagnosis, and treatment such as can be carried out by the general practitioner. 
The teachings of the author are in accordance with his belief that true conservatism is to 
be found in the middle course between the surgeon who operates too frequently and the 
orthopedist who seldom operates. 

MORRIS'S MATERIA MEDICA AND THERAPEUTICS. Fifth 
Edition, Revised. 
Essentials of Materia Medica, Therapeutics, and Prescription 
Writing. By Henry Morris, M.D., late Demonstrator of Thera- 
peutics, Jefferson Medical College, Philadelphia; Fellow of the College 
of Physicians, Philadelphia, etc. Crown octavo, 288 pages. Cloth, 
$1.00; interleaved for notes, Si. 25. 

[See Saunders' Question- Compends, page 21.] 

"This work, already excellent in the old edition, has been largely improved by revi- 
sion. " — American Practitioner and News. 

MORRIS, WOLFF, AND POWELL'S PRACTICE OF MEDICINE. 
Third Edition, Revised. 
Essentials of the Practice of Medicine. By Henry Morris, M.D., 
late Demonstrator of Therapeutics, Jefferson Medical College, Phila- 
delphia ; with an Appendix on the Clinical and Microscopic Examina- 
tion of Urine, by Lawrence Wolff. M. D. . Demonstrator of Chemistry, 
Jefferson Medical College, Philadelphia. Enlarged by some 300 essen- 
tial formula; collected and arranged by William M. Powell, M.D. 
Post-octavo, 488 pages. Cloth, 52.00. 

[See Saunders' Question- Compends, page 21.] 

" The teaching is sound, the presentation graphic ; matter full as can be desired, na6 
style attractive." — American Practitioner and News. 



18 Medical Publications of W. B. Saunders. 

MORTEN'S NURSE'S DICTIONARY. 

Nurse's Dictionary of Medical Terms and Nursing Treat- 
ment. Containing Definitions of the Principal Medical and Nursing 
Terms and Abbreviations ; of the Instruments, Drugs, Diseases, Acci- 
dents, Treatments, Operations, Foods, Appliances, etc. encountered 
in the ward or in the sick-room. By Honnor Morten, author of 
" How to Become a Nurse," etc. i6mo, 140 pages. Cloth, #1.00. 

" A handy, compact little volume, containing a large amount of general information, all 
of which is arranged in dictionary or encyclopedic form, thus facilitating quick reference. 
It is certainly of value to those for whose use it is published." — Chicago Clinical Review. 

NANCREDE'S ANATOMY. Fifth Edition. 

Essentials of Anatomy, including the Anatomy of the Viscera. 
By Charles B. Nancrede, M.D., Professor of Surgery and of Clini- 
cal Surgery in the University of Michigan, Ann Arbor. Crown octavo, 
388 pages; 180 illustrations. With an Appendix containing over 60 
illustrations of the osteology of the human body. Based upon Gray's 
Anatomy. Cloth, $1.00; interleaved for notes, $1.25. 
[See Saunders'' Question- Compends , page 21.] 

" For self-quizzing and keeping fresh in mind the knowledge of anatomy gained at 
school, it would not be easy to speak of it in terms too favorable." — American Practitioner. 

NANCREDE'S ANATOMY AND DISSECTION. Fourth Edition. 
Essentials of Anatomy and Manual of Practical Dissection. 

By Charles B. Nancrede, M.D., Professor of Surgery and of Clinical 
Surgery, University of Michigan, Ann Arbor. Post-octavo ; 500 pages, 
with full-page lithographic plates in colors, and nearly 200 illustrations. 
Extra Cloth (or Oilcloth for the dissection-room), $2.00 net. 

" It may in many respects be considered an epitome of Gray's popular work on general 
anatomy, at the same time having some distinguishing characteristics of its own to commend 
it. The plates are of more than ordinary excellence, and are of especial value to students 
in their work in the dissecting room." — Journal of the American Medical Association. 

NORRIS'S SYLLABUS OF OBSTETRICS. Third Edition, Revised. 
Syllabus of Obstetrical Lectures in the Medical Department 
of the University of Pennsylvania. By Richard C. Norris, 
A.M., M.D., Demonstrator of Obstetrics, University of Pennsylvania. 
Crown octavo, 222 pages. Cloth, interleaved for notes, $2.00 net. 

"This work is so far superior to others on the same subject that we take pleasure in 
calling attention briefly to its excellent features. It covers the subject thoroughly, and will 
prove invaluable both to the student and the practitioner." — Medical Record, New York. 

PENROSE'S DISEASES OF WOMEN. Second Edition, Revised. 
A Text=Book of Diseases of Women. By Charles B. Penrose, 
M.D., Ph.D., Professor of Gynecology in the University of Pennsyl- 
vania; Surgeon to the Gynecean Hospital, Philadelphia. Octavo 
volume of 529 pages, handsomely illustrated. Cloth, $3.50 net. 
"I shall value very highly the copy of Penrose's 'Diseases of Women* received. 

I have already recommended it to my class as THE BEST book."— Howard A. Kelly, 

Professor of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Md. 

"The book is to be commended without reserve, not only to the student but to the 

general practitioner who wishes to have the latest and best modes of treatment explained 

with absolute clearness." — Therapeutic Gazette. 






Medical Publications of W. B. Saunders. 19 

POWELL'S DISEASES OF CHILDREN. Second Edition. 

Essentials of Diseases of Children. By William M. Powell, 
M.D., Attending Physician to the Mercer House for Invalid Women 
at Atlantic City, N. J. ; late Physician to the Clinic for the Diseases of 
Children in the Hospital of the University of Pennsylvania. Crown 
octavo, 222 pages. Cloth, $1.00; interleaved for notes, $1.25. 
[See Saunders' Question- Compends, page 21.] 

"Contains the gist of all the best works in the department to which it relates." — 
American Practitioner and News. 

PRINGLE'S SKIN DISEASES AND SYPHILITIC AFFECTIONS. 
Pictorial Atlas of Skin Diseases and Syphilitic Affections 
(American Edition). Translation from the French. Edited by 
J. J. Pringle, M.B., F.R.C.P., Assistant Physician to the Middlesex 
Hospital, London. Photo-lithochromes from the famous models in 
the Museum of the Saint-Louis Hospital, Paris, with explanatory wood- 
cuts and text. In 12 Parts. Price per Part, $3.00. Complete in 
one volume, Half Morocco binding, $40.00 net. 

"I strongly recommend this Atlas. The plates are exceedingly well executed, and 
will be of great value to all studying dermatology." — Stephen Mackenzie, M.D. 

"The introduction of explanatory wood-cuts in the text is a novel and most important 
feature which greatly furthers the easier understanding of the excellent plates, than which 
nothing, we venture to say, has been seen better in point of correctness, beauty, and general 
merit." — New York Medical Journal. 

PYE'S BANDAGING. 

Elementary Bandaging and Surgical Dressing. With Direc- 
tions concerning the Immediate Treatment of Cases of Emergency. 
For the use of Dressers and Nurses. By Walter Pye, F.R.C.S., late 
Surgeon to St. Mary's Hospital, London. Small 121110, with over 80 
illustrations. Cloth, flexible covers, 75 cents net. 

" The directions are clear and the illustrations are good." — London Lancet. 

"The author writes well, the diagrams are clear, and the book itself is small and port- 
able, although the paper and type are good." — British Medical Journal. 

RAYMOND'S PHYSIOLOGY. 

A Manual of Physiology. By Joseph H. Raymond, A.M., M.D., 
Professor of Physiology and Hygiene and Lecturer on Gynecology in 
the Long Island College Hospital ; Director of Physiology in the 
Hoagland Laboratory, etc. 382 pages, with 102 illustrations in the 
text, and 4 full-page colored plates. Cloth, $1.25 net. 

" Extremely well gotten up, and the illustrations have been selected with care. The 
text is fully abreast with modern physiology." — British Medical Journal. 

RONTGEN RAYS. 

Archives of the Rontgen Ray (Formerly Archives of Clinical 
Skiagraphy). Edited by Sydney Rowland, M.A., M.R.C.S., and 
W. S. Hedley, M.D., M.R.C.S. A series of collotype illustrations, 
with descriptive text, illustrating the applications of the new photo- 
graphy to Medicine and Surgerv. Price per Part, $1.00. Now ready: 
Vol. I., Parts I. to IV.; Vol. II., Parts I., II. 




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They are the advance guard of "Student's Helps" — that do help. They are the 
leaders in their special line, well and authoritatively written by able men, who, as teachers in 
the large colleges, know exactly what is wanted by a student preparing for his examinations. 
The judgment exercised in the selection of authors is fully demonstrated by their professional 
standing. Chosen from the ranks of Demonstrators, Quiz-masters, and Assistants, most of 
them have become Professors and Lecturers in their respective colleges. 

Each book is of convenient size (5x7 inches), containing on an average 250 pages, 
profusely illustrated, and elegantly printed in clear, readable type, on fine paper. 

The entire series, numbering twenty-three volumes, has been kept thoroughly revised 
and enlarged when necessary, many of the books being in their fifth and sixth editions. 

TO SUM UP. 

Although there are numerous other Quizzes, Manuals, Aids, etc. in the market, none of 
them approach the "Blue Series of Question Compends;" and the claim is made for the 
following points of excellence : 

1. Professional distinction and reputation of authors. 

2. Conciseness, clearness, and soundness of treatment. 

3. Quality of illustrations, paper, printing, and binding. 

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"Where the work of preparing students' manuals is to end we cannot say, but the 
.Saunders Series, in our opinion, bears off the palm at present."— New York Medical Record. 



1. ESSENTIALS OF PHYSIOLOGY. By H. A. Hare, M.D. Third edition. 

revised and enlarged, (gl.oo net.) 

2. ESSENTIALS OF SURGERY. By Edward Martin, M.D. Sixth edition, 

revised, with an Appendix on Antiseptic Surgery. 

3. ESSENTIALS OF ANATOMY. By Charles B. Nancrede, M.D. Fifth 

edition, with an Appendix. 

4. ESSENTIALS OF MEDICAL CHEMISTRY, ORGANIC AND INORGANIC. 

By LAWRENCE Wolff, M.D. Fourth edition, revised, with an Appendix. 

5. ESSENTIALS OF OBSTETRICS. By W. Easterly Ashton, M.D. Fourth 

edition, revised and enlarged. 

6. ESSENTIALS OF PATHOLOGY AND MORBID ANATOMY. By C. E. 

Armand Semple, M.D. 

7. ESSENTIALS OF MATERIA MEDICA, THERAPEUTICS, AND PRE= 

SCRIPTION=WRITING. By Henry Morris, M.D. Fifth edition, revised. 

8. 9. ESSENTIALS OF PRACTICE OF MEDICINE. By Henry Morris, 

M.D. An Appendix on Urine Examination. By Lawrence Wolff, M.D. 
Third edition, enlarged by some 300 Essential Formula, selected from eminent 
authorities, by Wm. M. Powell, M.D. (Double number, $2.00.) 

10. ESSENTIALS OF GYNECOLOGY. By Edwin B. Cragin, M.D. Fourth 

edition, revised. 

11. ESSENTIALS OF DISEASES OF THE SKIN. By Henry W. Stelwagon, 

M.D. Third edition, revised and enlarged. ($1.00 net.) 

12. ESSENTIALS OF MINOR SURGERY, BANDAGING, AND VENEREAL 

DISEASES. By Edward Martin, M.D. Second ed., revised and enlarged. 

13. ESSENTIALS OF LEGAL MEDICINE, TOXICOLOGY, AND HYGIENE. 

By C. E. Armand Semple, M.D. 

14. ESSENTIALS OF DISEASES OF THE EYE, NOSE, AND THROAT. 

By Edward Jackson, M.D., and E. B. Gleason, M.D. Second ed., revised. 

15. ESSENTIALS OF DISEASES OF CHILDREN. By William M. Powell, 

M.D. Second edition. 

16. ESSENTIALS OF EXAMINATION OF URINE. By Lawrence Wolff, 

M.D. Colored " Yogel Scale." (75 cents.) 

17. ESSENTIALS OF DIAGNOSIS. By S. Solis Cohen, M.D., and A. A. Eshner, 

M.D. (#1.50 net.) 

18. ESSENTIALS OF PRACTICE OF PHARMACY. By Lucius E. Sayre. 

Second edition, revised and enlarged. 

20. ESSENTIALS OF BACTERIOLOGY. By M. V. Ball, M.D. Third edition, 

revised. 

21. ESSENTIALS OF NERVOUS DISEASES AND INSANITY. By John C. 

Shaw, M. D. Third edition, revised. 

22. Essentials of medical physics. By Fred j. brockway, m.d. 

Second edition, revised. ($1.00 net.) 

23. ESSENTIALS OF MEDICAL ELECTRICITY. By David D. Stewart, M.D., 

and Edward S. Lawrance, M.D. 

24. ESSENTIALS OF DISEASES OF THE EAR. By E. B. Gleason, M.D. 

Second edition, revised and greatly enlarged. 



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the SAUNDERS NEW SERIES OF MANUALS have been received by medical 
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condensations from present literature, but are ably written by well-known authors 
and practitioners, most of them being teachers in representative American colleges. 
Each volume is concisely and authoritatively written and exhaustive in detail, without 
being encumbered with the introduction of "cases," which so largely expand the 
ordinary text-book. These manuals will therefore form an admirable collection of 
advanced lectures, useful alike to the medical student and the practitioner: to the 
latter, too busy to search through page after page of elaborate treatises for what he 
wants to know, they will prove of inestimable value ; to the former they will afford 
safe guides to the essential points of study. 

The SAUNDERS NEW SERIES OF MANUALS are conceded to be superior 
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VOLUMES PUBLISHED. 

PHYSIOLOGY. By Joseph Howard Raymond, A.M., M.D., Professor of Physiology 
and Hygiene and Lecturer on Gynecology in the Long Island College Hospital; 
Director of Physiology in the Hoagland Laboratory, etc. Illustrated. Cloth, $1.25 net. 

SURGERY, General and Operative. By John Chalmers DaCosta, M.D., Clini- 
cal Professor of Surgery, Jefferson Medical College, Philadelphia ; Surgeon to the 
Philadelphia Hospital, etc. Second edition, thoroughly revised and greatly enlarged. 
Octavo, 900 pages, profusely illustrated. Cloth, $4.00 net ; Half Morocco, $5.00 net. 

DOSE-BOOK AND MANUAL OF PRESCRIPTION=WRITING. By E. Q. 

Thornton, M.D., Demonstrator of Therapeutics, Jefferson Medical College, Phila- 
delphia. Illustrated. Cloth, $1.25 net. 

SURGICAL ASEPSIS. By Cari. Beck, M.D., Surgeon to St. Mark's Hospital and 

to the New York German Poliklinik, etc. Illustrated. Cloth, #1.25 net. 

MEDICAL JURISPRUDENCE. By Henry C. Chapman, M.D. Professor of Insti- 
tutes of Medicine and Medical Jurisprudence in the Jefferson Medical College of Phila- 
delphia. Illustrated. Cloth, #1.50 net. 

SYPHILIS AND THE VENEREAL DISEASES. By James Nevins Hyde, M.D., 
Professor of Skin and Venereal Diseases, and Frank H. Montgomery, M.D., 
Lecturer on Dermatology and Genito-Urinary Diseases in Rush Medical College, 
Chicago. Profusely illustrated. (Double number.) Cloth, $2.50 net. 

PRACTICE OF MEDICINE. By George Roe Lockwood, M.D., Professor of 
Practice in the Woman's Medical College of the New York Infirmary ; Instructor in 
Physical Diagnosis in the Medical Department of Columbia College, etc. Illustrated. 
(Double number.) Cloth, $2.50 net. 

MANUAL OF ANATOMY. By Irving S. Haynes, M.D., Adjunct Professor of 
Anatomy and Demonstrator of Anatomy, Medical Department of the New York 
University, etc. Beautifully illustrated. (Double Number.) Cloth, $2.50 net. 

MANUAL OF OBSTETRICS. By W. A. Newman Dorland, M.D., Assistant 
Demonstrator of Obstetrics, University of Pennsylvania ; Chief of Gynecological Dis- 
pensary, Pennsylvania Hospital, etc. Profusely illustrated. (Double number.) Cloth, 
#2.50 net. 

DISEASES OF WOMEN. By J. Bland Sutton, F.R.C.S., Assistant Surgeon to 
Middlesex Hospital and Surgeon to Chelsea Hospital, London ; and Arthur E. 
Giles, M.D., B.Sc. Lond. , F.R.C.S. Edin., Assistant Surgeon to Chelsea Hospital, 
London. Handsomely illustrated. (Double number.) Cloth, $2.50 net. 



VOLUMES IN PREPARATION. 

NOSE AND THROAT. By D. Braden Kyle, M.D., Clinical Professor of Laryn- 
gology and Rhinology, Jefferson Medical College, Philadelphia; Consulting Laryngolo- 
gist, Rhinologist, and Otologist, St. Agnes' Hospital ; Bacteriologist to the Philadel- 
phia Orthopedic Hospital and Infirmary for Nervous Diseases, etc. 

NERVOUS DISEASES. By Charles W. Burr, M.D., Clinical Professor of Nervous 
Diseases, Medico-Chirurgical College, Philadelphia; Pathologist to the Orthopaedic 
Hospital and Infirmary for Nervous Diseases; Visiting Physician to the St. Joseph 
Hospital, etc. 

*** There will be published in the same series, at short intervals, carefully-prepared works 
on various subjects by prominent specialists. 



Pamphlet containing specimen pages, etc. sent free upon application. 



24 Medical Publications of W. B. Saunders. 

SAUNDBY'S RENAL AND URINARY DISEASES. 

Lectures on Renal and Urinary Diseases. By Robert Saundby, 
M.D. Edin., Fellow of the Royal College of Physicians, London, and 
of the Royal Medico-Chirurgical Society ; Physician to the General 
Hospital ; Consulting Physician to the Eye Hospital and to the Hos- 
pital for Diseases of Women ; Professor of Medicine in Mason College, 
Birmingham, etc. Octavo volume of 434 pages, with numerous illus- 
trations and 4 colored plates. Cloth, $2.50 net. 

" The volume makes a favorable impression at once. The style is clear and succinct. 
We cannot find any part of the subject in which the views expressed are not carefully thought 
out and fortified by evidence drawn from the most recent sources. The book may be cordially 
recommended." — British Medical Journal. 

SAUNDERS' POCKET MEDICAL FORMULARY. Fifth Edition, 
Revised. 

By William M. Powell, M.D., Attending Physician to the Mercer 
House for Invalid Women at Atlantic City, N. J. Containing 1800 
formulae selected from the best-known authorities. With an Appen- 
dix containing Posological Table, Formulae and Doses for Hypo- 
dermic Medication, Poisons and their Antidotes, Diameters of the 
Female Pelvis and Foetal Head, Obstetrical Table, Diet List for Various 
Diseases, Materials and Drugs used in Antiseptic Surgery, Treatment 
of Asphyxia from Drowning, Surgical Remembrancer, Tables of 
Incompatibles, Eruptive Fevers, Weights and Measures, etc. Hand- 
somely bound in flexible morocco, with side index, wallet, and flap. 
#1.75 net. 

" This little book, that can be conveniently carried in the pocket, contains an immense 
amount of material. It is very useful, and, as the name of the author of each prescription 
is given, is unusually reliable." — Medical Record, New York. 

SAUNDERS' POCKET MEDICAL LEXICON. Fourth Edition, 
Revised. 
A Dictionary of Terms and Words used in Medicine and 
Surgery. By John M. Keating, M.D., Fellow of the College of 
Physicians of Philadelphia; Editor of the "Cyclopaedia of Diseases 
of Children," etc.; Author of the "New Pronouncing Dictionary of 
Medicine;" and Henry Hamilton, Author of "A New Translation 
of Virgil's ^Eneid into English Verse;" Co-Author of the "New 
Pronouncing Dictionary of Medicine." 321110, 280 pages. Cloth, 
75 cents; Leather Tucks, $1.00. 

" Remarkably accurate in terminology, accentuation, and definition." — Journal of the 
American Medical Association . 



SAYRE'S PHARMACY. Second Edition, Revised. 

Essentials of the Practice of Pharmacy. By Lucius E. Sayre, 
M.D., Professor of Pharmacy and Materia Medica in the University of 
Kansas. Crown octavo, 200 pages. Cloth, $1.00; interleaved for 
notes, $1.25. 

[See Saunders'' Question- Compends, page 21.] 

" The topics are treated in a simple, practical manner, and the work forms a very useful 
student's manual." — Boston Medical and Surgical Journal. 



Medical Publications of W. B. Saunders. 25 

SEMPLE'S LEGAL MEDICINE, TOXICOLOGY, AND HYGIENE. 
Essentials of Legal Medicine, Toxicology, and Hygiene. By 

C. E. Armand Semple, B.A., M. B. Cantab., M. R. C. P. Lond., 
Physician to the Northeastern Hospital for Children, Hackney, etc. 
Crown octavo, 2 1 2 pages ; 130 illustrations. Cloth, $1. 00; interleaved 
for notes, #1.25. 

[See Saunders' 1 Question- Compends, page 21.] 

" No general practitioner or student can afford to be without this valuable work. The 
subjects are dealt with by a masterly hand." — -London Hospital Gazette. 

SEMPLE'S PATHOLOGY AND MORBID ANATOMY. 

Essentials of Pathology and Morbid Anatomy. By C. E. 

Armand Semple, B.A., M.B. Cantab., M.R.C.P. Lond., Physician to 
the Northeastern Hospital for Children, Hackney, etc. Crown octavo, 
174 pages; illustrated. Cloth, $1. 00; interleaved for notes, $1.25. 
[See Saunders' Question- Compends, page 21.] 

" Should take its place among the standard volumes on the bookshelf of both student 
and practitioner." — London Hospital Gazette. 

SENN'S GENITOURINARY TUBERCULOSIS. 

Tuberculosis of the Genito=Urinary Organs, Male and Female. 

By Nicholas Senn, M.D., Ph.D., LL.D., Professor of the Practice of 
Surgery and of Clinical Surgery, Rush Medical College, Chicago. 
Handsome octavo volume of 320 pages, illustrated. Cloth, $3.00 net. 

" An important book upon an important subject, and written by a man of mature judg- 
ment and wide experience. ' The author has given us an instructive book upon one of the 
most important subjects of the day." — Clinical Reporter. 

" A work which adds another to the many obligations the profession owes the talented 
author." — Chicago Medical Recorder. 

SENN'S SYLLABUS OF SURGERY. 

A Syllabus of Lectures on the Practice of Surgery, arranged 
in conformity with " An American Text=Book of Surgery." By 

Nicholas Senn, M.D., Ph.D., Professor of the Practice of Surgery and 
of Clinical Surgery in Rush Medical College, Chicago. Cloth, $2.00. 

" This syllabus will be found of service by the teacher as well as the student, the work 
being superbly done. There is no praise too high for it. No surgeon should be without 
it." — New York Medical Times. 

SENN'S TUMORS. 

Pathology and Surgical Treatment of Tumors. By N. Senn, 
M.D., Ph.D., LL.D., Professor of Surgery and of Clinical Surgery, 
Rush Medical College ; Professor of Surgery, Chicago Polyclinic ; 
Attending Surgeon to Presbyterian Hospital ; Surgeon-in-Chief, St. 
Joseph's Hospital, Chicago. Octavo volume of 710 pages, with 515 
engravings, including full-page colored plates. Cloth, $6.00 net; 
Half Morocco, $7.00 net. 

"The most exhaustive of any recent book in English on this subject. It is well illus- 
trated, and will doubtless remain as the principal monograph on the subject in our language 
for some years. The book is handsomely illustrated and printed, and the author has given a 
notable and lasting contribution to surgery." — Journal of the American Medical Association. 



26 Medical Publications of W. B. Saunders. 

SHAW'S NERVOUS DISEASES AND INSANITY. Third Edition, 
Revised. 
Essentials of Nervous Diseases and Insanity. By John C. 
Shaw, M.D., Clinical Professor of Diseases of the Mind and Nervous 
System, Long Island College Hospital Medical School ; Consulting 
Neurologist to St. Catherine's Hospital and to the Long Island College 
Hospital. Crown octavo, 186 pages; 48 original illustrations. Cloth, 
$1.00 ; interleaved for notes, #1.25. 

[See Saunders' Question- Compends, page 21.] 
"Clearly and intelligently written." — Boston Medical and Surgical Journal. 
"There is a mass of valuable material crowded into this small compass." — American 
Medico- Surgical Bulletin. 

STARR'S DIETS FOR INFANTS AND CHILDREN. 

Diets for Infants and Children in Health and in Disease. Ey 

Louis Starr, M.D., Editor of "An American Text-Book of the 
Diseases of Children." 230 blanks (pocket-book size), perforated 
and neatly bound in flexible morocco. $1.25 net. 

The first series of blanks are prepared for the first seven months of infant life ; each 
blank indicates the ingredients, but not the quantities, of the food, the latter directions being 
left for the physician. After the seventh month, modifications being less necessary, the diet 
lists are printed in full. Formulas for the preparation of diluents and foods are appended. 

STELW AGON'S DISEASES OF THE SKIN. Third Edition, Revised. 
Essentials of Diseases of the Skin. By Henry W. Stelwagon, 
M.D., Clinical Professor of Dermatology in the Jefferson Medical 
College, Philadelphia ; Dermatologist to the Philadelphia Hospital ; 
Physician to the Skin Department of the Howard Hospital, etc. 
Crown octavo, 270 pages; 86 illustrations. Cloth, |i.oonet; inter- 
leaved for notes, #1.25 net. 

[See Saunders' Question- Compends, page 21.] 
" The best student's manual on skin diseases we have yet seen." — Times and Register. 

STENGEL'S PATHOLOGY. 

A Manual of Pathology. By Alfred Stengel, M.D., Physician 
to the Philadelphia Hospital ; Professor of Clinical Medicine in the 
Woman's Medical College; Physician to the Children's Hospital; 
late Pathologist to the German Hospital, Philadelphia, etc. In 
Preparation. 

STEVENS' MATERIA MEDICA AND THERAPEUTICS. Second 
Edition, Revised. 
A Manual of Materia Medica and Therapeutics. By A. A. 

Stevens, A.M., M.D., Lecturer on Terminology and Instructor in 
Physical Diagnosis in the University of Pennsylvania; Demonstrator 
of Pathology in the Woman's Medical College of Philadelphia. Post- 
octavo, 445 pages. Cloth, $2.25. 

" The author has faithfully presented modern therapeutics in a comprehensive work, 
and, while intended particularly for the use of students, it will be found a reliable guide and 
sufficiently comprehensive for the physician in practice." — University Medical Magazine. 






Medical Publications of W. B. Saunders. 27 

STEVENS' PRACTICE OF MEDICINE. Fifth Edition, Revised. 
A Manual of the Practice of Medicine. By A. A. Stevens, A.M., 
M.D., Lecturer on Terminology and Instructor in Physical Diagnosis 
in the University of Pennsylvania ; Demonstrator of Pathology in 
the Woman's Medical College of Philadelphia. Specially intended 
for students preparing for graduation and hospital examinations. Post- 
octavo, 511 pages; illustrated. Flexible leather, $2.50. 

"The frequency with which new editions of this manual are demanded bespeaks its 
popularity. It is an excellent condensation of the essentials of medical practice for the 
student, and maybe found also an excellent reminder for the busy physician." — Buffalo 
Medical Journal. 

STEWART'S PHYSIOLOGY. 

A Manual of Physiology, with Practical Exercises. For 
Students and Practitioners. By G. N. Stewart, M.A., M.D., 
D.Sc, lately Examiner in Physiology, University of Aberdeen, and 
of the New Museums, Cambridge University ; Professor of Physiology 
in the Western Reserve University, Cleveland, Ohio. Octavo volume 
of 800 pages; 278 illustrations in the text, and 5 colored plates. 
Cloth, $3.50 net. 

" It will make its way by sheer force of merit, and amply deserves to do so. It is one 
of the very best English text-books on the subject." — Lottdon Lancet. 

"Of the many text-books of physiology published, we do not know of one that so 
nearly comes up to the ideal as does Prof. Stewart's volume." — British Medical Journal. 

STEWART AND LAWRANCE'S MEDICAL ELECTRICITY. 

Essentials of Medical Electricity. By D. D. Stewart, M.D., 
Demonstrator of Diseases of the Nervous System and Chief of the 
Neurological Clinic in the Jefferson Medical College; and E. S. 
Lawrance, M.D., Chief of the Electrical Clinic and Assistant Demon- 
strator of Diseases of the Nervous System in the Jefferson Medical 
College, etc. Crown octavo, 158 pages; 65 illustrations. Cloth, 
$1.00; interleaved for notes, $1.25. 

[See Saunders'' Question- Compends, page 21.] 

" Throughout the whole brief space at their command the authors show a discriminating 
knowledge of their subject." — Medical News. 

STONEY'S NURSING. Second Edition, Revised. 

Practical Points in Nursing. For Nurses in Private Practice. 

By Emily A. M. Stoney, Graduate of the Training-School for Nurses, 
• Lawrence, Mass.; late Superintendent of the Training-School for 
Nurses, Carney Hospital, South Boston, Mass. 456 pages, illustrated 
with 73 engravings in the text, and 8 colored and half-tone plates. 
Cloth, $1.75 net. 

" There are few books intended for non-professional readers which can be so cordially 
endorsed by a medical journal as can this one." — Therapeutic Gazette. 

" This is a well-written, eminently practical volume, which covers the entire range of 
private nursing as distinguished from hospital nursing, and instructs the nurse how best to 
meet the various emergencies which may arise, and how to prepare everything ordinarily 
needed in the illness of her patient." — A?nerican Journal of Obstetrics and Diseases of 
Women and Children. 

" It is a work that the physician can place in the hands of his private nurses with the 
assurance of benefit." — Ohio Medical Journal. 



28 Medical Publications of W. B. Saunders. 

SUTTON AND GILES' DISEASES OF WOMEN. 

Diseases of Women. By J. Bland Sutton, F.R.C.S., Assistant 
Surgeon to Middlesex Hospital, and Surgeon to Chelsea Hospital, 
London; and Arthur E. Giles, M.D., B.Sc. Lond., F.R.C.S. Edin., 
Assistant Surgeon to Chelsea Hospital, London. 436 pages, hand- 
somely illustrated. Cloth, $2.50 net. 

"The book is very well prepared, and is certain to be well received by the medical 
public. ' ' — British Medical Journal. 

"The text has been carefully prepared. Nothing essential has been omitted, and its 
teachings are those recommended by the leading authorities of the day." — Journal of the 
American Medical Association. 

THOMAS'S DIET LISTS AND SICK=ROOM DIETARY. 

Diet Lists and Sick=Room Dietary. By Jerome B. Thomas, 
M.D., Visiting Physician to the Home for Friendless Women and 
Children and to the Newsboys' Home ; Assistant Visiting Physician 
to the Kings County Hospital. Cloth, $1.50. Send for sample sheet. 

" The idea is good, and the lists are copious." — London Lancet. 

"Its practical usefulness places it among the requirements of every practitioner." — ■ 
Chicago Medical Recorder. 

THORNTON'S DOSE=BOOK AND PRESCRIPTION=WRITINQ. 

Dose=Book and Manual of Prescription=Writing. By E. Q. 

Thornton, M.D., Demonstrator of Therapeutics, Jefferson Medical 
College, Philadelphia. 334 pages, illustrated. Cloth, #1.25 net. 

" Full of practical suggestions; will take its place in the front rank of works of this 
sort." — Medical Record, New York. 

VAN VALZAH AND NISBET'S DISEASES OF THE STOMACH. 
Diseases of the Stomach. By William W. Van Valzah, M.D., 
Professor of General Medicine and Diseases of the Digestive System 
and the Blood, New York Polyclinic; and J. Douglas Nisbet, M.D., 
Adjunct Professor of General Medicine and Diseases of the Digestive 
System and the Blood, New York Polyclinic. Octavo volume of 674 
pages, illustrated. Cloth, $3.50 net. 

VIERORDT'S MEDICAL DIAGNOSIS. Fourth Edition, Revised. 
Medical Diagnosis. By Dr. Oswald Vierordt, Professor of Medi- 
cine at the University of Heidelberg. Translated, with additions, 
from the fifth enlarged German edition, with the author's permission, 
by Francis H. Stuart, A. M., M. D. Handsome royal octavo volume 
of 600 pages; 194 fine wood-cuts in text, many of them in colors. 
Cloth, $4.00 net; Sheep or Half Morocco, $5.00 net; Half Russia, 
$5.50 net. 

" A treasury of practical information which will be found of daily use to every busy 
practitioner who will consult it." — C. A. LlNDSLEV, M.D., Professor of the Theory and 
Practice of Medicine, Yale University. 

" Rarely is a book published with which a reviewer can find so little fault as with the 
volume before us. Each particular item in the consideration of an organ or apparatus, which 
is necessary to determine a diagnosis of any disease of that organ, is mentioned ; nothing 
seems forgotten. The chapters on diseases of the circulatory and digestive apparatus and 
nervous system are especially full and valuable. The reviewer would repeat that the book is 
one of the best — probably the best — which has fallen into his hands." — University Medical 
Magazine. 



Medical Publications of W. B. Saunders. 29 

WARREN'S SURGICAL PATHOLOGY AND THERAPEUTICS. 

Surgical Pathology and Therapeutics. By John Collins Warren, 
M.D., LL.D., Professor of Surgery, Medical Department Harvard 
University; Surgeon to the Massachusetts General Hospital, etc. 
Handsome octavo volume of 832 pages; 136 relief and lithographic 
illustrations, 33 of which are printed in colors, and all of which were 
drawn by William J. Kaula from original specimens. Cloth, $6.00 
net; Half Morocco, $7.00 net. 

"There is the work of Dr. Warren, which I think is the most creditable book on 
Surgical Pathology, and the most beautiful medical illustration of the bookmaker's art, that 
has ever been issued from the American press." — Dr. Roswell Park, in the Harvard 
Graduate Magazine. 

" The handsomest specimen of bookmaking that has ever been issued from the American 
medical press." — American Journal of the Medical Sciences. 

" A most striking and very excellent feature of this book is its illustrations. Without 
exception, from the point of accuracy and artistic merit, they are the best ever seen in a work 
of this kind. Many of those representing microscopic pictures are so perfect in their coloring 
and detail as almost to give the beholder the impression that he is looking down the barrel 
of a microscope at a well-mounted section." — Annals of Surgery. 

WEST'S NURSING. 

An American Text=Book of Nursing. By American Teachers. 
Edited by Roberta M. West, late Superintendent of Nurses in the 
Hospital of the University of Pennsylvania. In Preparation. 

WOLFF ON EXAMINATION OF URINE. 

Essentials of Examination of Urine. By Lawrence Wolff, M.D., 
Demonstrator of Chemistry, Jefferson Medical College, Philadelphia, 
etc. Colored (Vogel) urine scale and numerous illustrations. Crown 
octavo. Cloth, 75 cents. 

[See Saunders' Question- Compends, page 21.] 
" A very good work of its kind — very well suited to its purpose." — Times and Register. 

WOLFF'S MEDICAL CHEMISTRY. Fourth Edition, Revised. 
Essentials of Medical Chemistry, Organic and Inorganic. 

Containing also Questions on Medical Physics, Chemical Physiology, 
Analytical Processes, Urinalysis, and Toxicology. By Lawrence 
Wolff, M.D., Demonstrator of Chemistry, Jefferson Medical College, 
Philadelphia, etc. Crown octavo, 218 pages. Cloth, $1.00; inter- 
leaved for notes, $1.25. 

[See Saunders' Question- Compends, page 21.] 

"The scope of this work is certainly equal to that of the best course of lectures on 
Medical Chemistry." — Pharmaceutical Era. 



CLASSIFIED LIST 



Medical Publications 



W. B. SAUNDERS, 

925 Walnut Street, Philadelphia. 



ANATOMY, EMBRYOLOGY, 
HISTOLOGY. 

Clarkson — A Text-Book of Histology, 9 
Haynes — A Manual of Anatomy, . . . 13 
Heisler — A Text- Book of Embryology, 13 
Nancrede — Essentials of Anatomy, . . 18 
Nancrede — Essentials of Anatomy and 

Manual of Practical Dissection, ... 18 
Semple — Essentials of Pathology and 

Morbid Anatomy, 25 

BACTERIOLOGY. 

Ball — Essentials of Bacteriology, ... 6 
Crookshank — A Text-Book of Bacteri- 
ology, 10 

Frothingham — Laboratory Guide, . . 11 
Mallory and Wright — Pathological 

Technique, 16 

McFarland — Pathogenic Bacteria, . . 17 

CHARTS, DIET-LISTS, ETC. 

Griffith— Infant's Weight Chart, ... 12 

Hart — Diet in Sickness and in Health, . 13 

Keen — Operation Blank, 15 

Laine — Temperature Chart, . . . 15 

Meigs — Feeding in Early Infancy, . . 17 

Starr — Diets for Infants and Children, . 26 
Thomas — Diet-Lists and Sick-Room 

Dietary, 28 

CHEMISTRY AND PHYSICS. 

Brockway — Essentials of Medical Phys- 
ics, •. . 7 

Wolff — Essentials of Medical Chemistry, 29 

CHILDREN. 

An American Text-Book of Diseases 

of Children 3 

Griffith— Care of the Baby, 12 

Griffith— Infant's Weight Chart, ... 12 

Meigs — Feeding in Early Infancy, . . 17 

Powell — Essentials of Dis. of Children, 19 

Starr — Diets for Infants and Children, . 26 

DIAGNOSIS. 

Cohen and Eshner — Essentials of Di- 
agnosis, 9 

Corwin — Physical Diagnosis, .... 9 

Macdonald — Surgical Diagnosis and 
Treatment, 16 

Vierordt — Medical Diagnosis, .... 28 

DICTIONARIES. 

Keating — Pronouncing Dictionary, . . 14 

Morten — Nurse's Dictionary, .... 18 

Saunders' Pocket Medical Lexicon, . 24 



EYE, EAR, NOSE, AND THROAT. 

An American Text- Book of Diseases 

of the Eye, Ear, Nose, and Throat, . 3 
Casselberry — Dis. of Nose and Throat, 8 
De Schweinitz — Diseases of the Eye, . IO 
Gleason — Essentials of Dis. of the Ear, 11 
Jackson and Gleason — Essentials of 

Diseases of the Eye, Nose, and Throat, 14 
Kyle — Diseases of the Nose and Throat, 15 

GENITOURINARY. 

An American Text-Book of Genito- 
urinary and Skin Diseases, 4 

Hyde and Montgomery — Syphilis and 
the Venereal Diseases, 13 

Martin — Essentials of Minor Surgery, 
Bandaging, and Venereal Diseases, . 16 

Saundby — Renal and Urinary Diseases, 24 

Senn — Genito-Urinary Tuberculosis, . 25 

GYNECOLOGY. 

American Text-Book of Gynecology, 4 

Cragin — Essentials of Gynecology, . . 10 

Garrigues — Diseases of Women, ... 11 

Long — Syllabus of Gynecology, ... 15 

Penrose — Diseases of Women, .... 18 

Sutton and Giles — Diseases of Women, 28 

MATERIA MEDICA, PHARMACOL- 
OGY, AND THERAPEUTICS. 

An American Text-Book of Applied 

Therapeutics, .... 3 

Butler — Text-Book of Materia Medica, 

Therapeutics and Pharmacology, ... 8 
Cerna — Notes on the Newer Remedies, 8 
Griffin — Materia Med. and Therapeutics, 12 
Morris — Essentials of Materia Medica 

and Therapeutics, . . 17 

Saunders' Pocket Medical Formulary, 24 
Sayre — Essentials of Pharmacy, ... 24 
Stevens — Essentials of Materia Medica 

and Therapeutics, 26 

Thornton — Dose-Book and Manual of 

Prescription-Writing, 28 

Warren— Surgical Pathology and Ther- 
apeutics, 29 

MEDICAL JURISPRUDENCE AND 
TOXICOLOGY. 

An American Text-Book of Legal 
Medicine and Toxicology, 4 

Chapman — Medical Jurisprudence and 
Toxicology, 8 

Semple — Essentials of Legal Medicine, 
Toxicology, and Hygiene, 25 



Medical Publications of W. B. Saunders. 



31 



NERVOUS AND MENTAL 
DISEASES, ETC. 

Burr — Nervous Diseases, 7 

Chapin — Compendium of Insanity, . . 8 
Church and Peterson — Nervous and 

Mental Diseases, 9 

Shaw — Essentials of Nervous Diseases 

and Insanity 26 

NURSING. 

An American Text-Book of Nursing, 29 

Griffith— The Care of the Baby, ... 12 

Hampton— Nursing 12 

Hart — Diet in Sickness and in Health, 13 

Meigs — Feeding in Early Infancy, . . 17 

Morten — Nurse's Dictionary, .... 18 

Stoney — Practical Points in Nursing, . 27 

OBSTETRICS. 

An American Text-Book of Obstetrics, 4 
Ashton— Essentials of Obstetrics, . 6 

Boislitiiere — Obstetric Accidents, Emer 

gencies, and Operations, .... 
Dorland — Manual of Obstetrics, . 
Hirst — Text-Book of Obstetrics, . 
Norris — Syllabus of Obstetrics, . . 

PATHOLOGY. 

An American Text-Book of Pathology, 5 
Mallory and Wright — Pathological 

Technique, 16 

Semple — Essentials of Pathology and 

Morbid Anatomy, . . 25 

Senn — Pathology and Surgical Treat- 
ment of Tumors, 25 

Stengel — Manual of Pathology, ... 26 
Warren — Surgical Pathology and Thera- 
peutics, 29 

PHYSIOLOGY. 

An American Text-Book of Physi- 
ology 5 

Hare — Essentials of Physiology, ... 13 
Raymond — Manual of Physiology, . . 19 
Stewart — Manual of Physiology, ... 27 

PRACTICE OF MEDICINE. 

An American Text-Book of the The- 
ory and Practice of Medicine, .... 5 

An American Year-Book of Medicine 
and Surgery, 6 

Anders — Text-Book of the Practice of 
Medicine, 6 

Lockwood — Manual of the Practice of 
Medicine, 15 

Morris — Essentials of the Practice of 
Medicine, 17 

Rowland and Hedley — Archives of 
the Roentgen Ray, 19 

Stevens — Manual of the Practice of 
Medicine, 27 

SKIN AND VENEREAL. 

An American Text-Book of Genito- 
urinary and Skin Diseases, 3 



Hyde and Montgomery — Syphilis and 
the Venereal Diseases, 13 

Martin — Essentials of Minor Surgery, 
Bandaging, and Venereal Diseases, . 16 

Pringle — Pictorial Atlas of Skin Dis- 
eases and Syphilitic Affections, ... 19 

Stelwagon — Essentials of Diseases of 
the Skin 26 

SURGERY. 

An American Text-Book of Surgery, 5 
An American Year-Book of Medicine 

and Surgery, 6 

Beck — Manual of Surgical Asepsis, . . 7 
DaCosta — Manual of Surgery, .... 10 

Keen— Operation Blank, 15 

Keen — The Surgical Complications and 

Sequels of Typhoid Fever, 15 

Macdonald — Surgical Diagnosis and 

Treatment, 16 

Martin — Essentials of Minor Surgery, 

Bandaging, and Venereal Diseases, . 16 
Martin — Essentials of Surgery, .... 16 

Moore — Orthopedic Surgery, 17 

Pye — Elementary Bandaging and Surgi- 
cal Dressing 19 

Rowland and Hedley— Archives of 
the Roentgen Ray, ........ 19 

Senn — Genito-Urinary Tuberculosis, . 25 

Senn - Syllabus of Surgery 25 

Senn — Pathology and Surgical Treat- 
ment of Tumors, . 25 

Warren — Surgical Pathology and Ther- 
apeutics, 29 

URINE AND URINARY DISEASES. 

Saundby — Renal and Urinary Diseases, 24 
Wolff — Essentials of Examination of 
Urine, 29 



MISCELLANEOUS. 

Bastin — Laboratory Exercises in Bot- 
any. 7 

Gould and Pyle — Anomalies and Curi- 
osities of Medicine, 11 

Keating — How to Examine for Life 
Insurance, 14 

Keen — Surgical Complications and Se- 
quels of Typhoid Fever, 15 

Rowland and Hedley — Archives of 
the Roentgen Ray, 19 

Saunders' Medical Hand-Atlases, . . 2 

Saunders' New Series of Manuals, 22, 23 

Saunders' Pocket Medical Formulary, 24 

Saunders' Question-Compends, . . 20, 21 

Senn — Pathology and Surgical Treat- 
ment of Tumors . 25 

Stewart and Lawrance — Essentials of 
Medical Electricity, 27 

Thornton — Dose-Book and Manual of 
Prescription-Writing, 28 

Van Valzah and Nisbet— Diseases of 
the Stomach 28 



In Preparation for Early Publication. 



AN AMERICAN TEXT=BOOK OF DISEASES OF THE EYE, EAR, NOSE, 
AND THROAT. 

Edited by G. E. de Schweinitz, M.D., Professor of Ophthalmology in the Jeffer- 
son Medical College, Philadelphia; and B. Alexander Randall, M.D., Professor 
of Diseases of the Ear in the University of Pennsylvania and in the Philadelphia 
Polyclinic. 

AN AMERICAN TEXT=BOOK OF PATHOLOGY. 

Edited by JOHN Guiteras, M.D., Professor of General Pathology and of Morbid 
Anatomy in the University of Pennsylvania; and David Riesman, M.D. , Demon- 
strator of Pathological Histology in the University of Pennsylvania. 

AN AMERICAN TEXT-BOOK OF LEGAL MEDICINE AND TOXICOLOGY. 

Edited by Frederick Peterson, M.D., Clinical Professor of Mental Diseases in 
the Woman's Medical College, New York ; Chief of Clinic, Nervous Department, 
College of Physicians and Surgeons, New York ; and Walter S. Haines, M.D., 
Professor of Chemistry, Pharmacy, and Toxicology in Rush Medical College, Chicago, 
Illinois. 

STENGEL'S PATHOLOGY. 

A Manual of Pathology. By Alfred Stengel, M. D., Physician to the 
Philadelphia Hospital; Professor of Clinical Medicine in the Woman's Medical 
College; Physician to the Children's Hospital; late Pathologist to the German 
Hospital, Philadelphia, etc. 

CHURCH AND PETERSON'S NERVOUS AND MENTAL DISEASES. 

Nervous and Mental Diseases. By Archibald Church, M.D., Professor of 
Mental Diseases and Medical Jurisprudence in the Northwestern University Medical 
School, Chicago ; and Frederick Peterson, M.D. , Clinical Professor of Mental 
Diseases in the Woman's Medical College, New York ; Chief of Clinic, Nervous 
Department, College of Physicians and Surgeons, New York. 

HEISLER'S EMBRYOLOGY. 

A Text=Book of Embryology. By John C. Heisler, M.D., Professor of 
Anatomy in the Medico-Chirurgical College, Philadelphia. 

KYLE ON THE NOSE AND THROAT. 

Diseases of the Nose and Throat. By D. Braden Kyle, M. D., Clinical Pro- 
fessor of Laryngology and Rhinology, Jefferson Medical College, Philadelphia; Con- 
sulting Laryngologist, Rhinologist, and Otologist, St. Agnes' Hospital; Bacteriologist 
to the Philadelphia Orthopedic Hospital and Infirmary for Nervous Diseases, etc. 

HIRST'S OBSTETRICS. 

A Text=Book of Obstetrics. By Barton Cooke Hirst, M.D., Professor of 
Obstetrics in the University of Pennsylvania. 

WEST'S NURSING. 

An American Text-Book of Nursing. By American Teachers. Edited by 
Roberta M. West, Late Superintendent of Nurses in the Hospital of the University 
of Pennsylvania. 






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